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Based on interview and observation, the facility failed to maintain their building free of penetrations, as evidenced by penetrations that had not been sealed. This condition affected the one of five floors at the Mission Laguna Beach campus, and could result in the passage of smoke from one part of the facility to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with maintenance staff, on 6/20/12, the facility walls and ceilings were observed.
Mission Laguna Beach
1. At 10:03 a.m., on the 1st floor in the Radiation Oncology Treatment Planning Office, there were two 2 inch penetrations on the bottom of the right hand wall.
2. At 10:34 a.m., on the 1st floor in the Pharmacy Storage Area, there was a 2 inch penetration around a duct that passed through a wall.
3. At 10:38 a.m., in materials Management, there was a 3 inch by 4 inch penetration in the sheetrock of the column near the entrance door.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by the failure to repair and seal penetrations in the walls and ceilings. This could result in the spread of smoke or fire from one smoke compartment to the next smoke compartment, and affected one of four floors in Tower I at the Mission Viejo Campus.

Findings:

During a tour of the facility with engineering staff, walls and ceilings were observed.
Tower I
On 6/19/12, at 10:10 a.m., Environmental Services Room 1-381 had an approximately 1/2 inch unsealed penetration in the upper left hand corner.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not latch, and by doors held open by magnets tied into the fire alarm system failed to release and fully close. This deficient condition affected three of five floors and had the potential to allow the migration of smoke or fire in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

Findings:

During a tour of the facility with a staff member on 6/20/12, the corridor doors were observed.
Mission Laguna Beach
1. At 9:33 a.m., on the 4th floor in Group Room 2 #423, the door was equipped with a self closing mechanism. When the door was held fully open and released, the door failed to positively latch when fully closed.
2. At 11:42 a.m., on the 2nd floor in Same Day Surgery Ambulatory Room 2, the doors were equipped with self closing mechanisms. The left hand door did not fully close and latch.
3. At 2:17 p.m., on the 4th floor room 401, the door released from the magnet when the fire alarm system was activated. The door remained fully open and failed to fully close and latch.
4. At 2:17 p.m., on the 4th floor room 401, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
5. At 2:17 p.m., on the 4th floor room 403, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
6. At 2:17 p.m., on the 4th floor room 406, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
7. At 2:30 p.m., on the 3rd floor room 323, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.



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Mission Laguna
1. At 9:35 a.m., Patient Room 302 self-closing door failed to fully close and latch.
2. At 9:38 a.m., Patient Room 306 self-closing door failed to fully close and latch.
3. At 9:40 a.m., Patient Room 307 self-closing door failed to latch shut.
4. At 9:42 a.m., Third Floor ICU Supply Room self-closing door failed to latch shut.
5. At 9:44 a.m., Patient Room 321 self-closing door failed to latch shut.
6. At 9:48 a.m., Patient Room 355 self-closing door failed to fully close and latch shut.
7. At 9:52 a.m., Clean Utility Storage across from Patient Room 306 self-closing door failed to fully close and latch shut.
8. At 11:20 a.m., Second floor Entrance door to Emergency Room by Treatment Room 2 failed to latch shut.
9. At 11:25 a.m., Emergency Room 9 door was blocked from closing by a chair.
10. At 11:27 a.m., Emergency Room 10 door was blocked from closing by a chair.
11. At 11:35 a.m., Radiology Dressing Room door failed to latch shut.
12. At 11:40 a.m., X-Ray Room 6 door failed to latch shut.
13. At 11:50 a.m., Dexa Bone Density Room door failed to fully close and latch shut.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not properly latch and by doors that were impeded from closing. This affected one of five floors in Tower I, and one of one floor in the Pavilion, at the Mission Viejo Campus and could result in the migration of fire or smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.
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.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During a tour of the facility with a staff member, the corridor doors were observed.
Mission Viejo - Pavilion
1. On 6/19/12, at 11:06 a.m., in the Clean Linen Room # P-1319, the door was equipped with a self closing mechanism. When the door was opened to the full extent and released, the door failed to positively latch.
2. On 6/19/12, at 11:08 a.m., the door to Room #P-141 was equipped with a self closing mechanism. The door was held open with a door wedge. When the door was opened to the full extent and released, the door failed to positively latch.
3. On 6/19/12, at 11:12 a.m., the door to Room #P-140 was equipped with a self closing mechanism. The door was held open with a chair propped up against the door. When the door was opened to the full extent and released, the door failed to positively latch.
4. On 6/19/12, at 11:1308 a.m., the door to Room #P-139 was equipped with a self closing mechanism. The door was held open with an isolation cart that was propped up against the door. When the door was opened to the full extent and released, the door failed to positively latch.
5. On 6/19/12, at 11:21 a.m., in the Medtele Break Room #P-1350, the door was equipped with a self closing mechanism. When the door was opened to the full extent and released, the door failed to positively latch.
6. On 6/19/12, at 11:49 a.m., in the Nuclear Medicine2 Room #P-165, the door was obstructed from closing by the bed in the room.
7. On 6/19/12, at 1:39 p.m., in Room #P-151, the door was held open by a trash can.
8. On 6/19/12, at 1:42 p.m., in Room #P-154, the door was held open by a trash can.
9. On 6/19/12, at 1:40 p.m., in Room #P-1405, the door was equipped with a self closing mechanism, and the door was held open by a trash can.



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Tower I
1. On 6/19/12, at 10:15 a.m., Patient Room 1-308 door was difficult to open when shut.
2. On 6/19/12, at 10:30 a.m., Clinical Work Station Room 1-399 self-closing door failed to fully close and latch.
3. On 6/19/12, at 11:50 a.m., Emergency Exam Room 1-106 door failed to latch.
4. On 6/19/12, at 11:55 a.m., Emergency Exam Room 1-105 door failed to latch.
5. On 6/19/12, at 2:10 p.m., Pharmacy Office 1-080 self-closing door failed to latch.

Pavilion
1. On 6/21/12, at 10:10 a.m., Operating Rooms Environmental Services Room double door failed to latch.
2. On 6/21/12, at 10:17 a.m., Operating Room 3 secondary door was equipped with a roller latch.
3. On 6/21/12, at 10:20 a.m., Operating Room 8 double door failed to latch.
4. On 6/21/12, at 10:28 a.m., Operating Room 4 secondary door was equipped with a roller latch.

Based on observation, the facility failed to maintain corridor doors as evidenced by a corridor doors that failed to close and latch when tested. This affected one of four floors at the Mission Viejo Campus, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with a staff member, the corridor doors were observed.
Tower II
1. On 6/18/12, at 1:40 p.m., Linen Room 2-464 self-closing door failed to fully close and latch shut.
2. On 6/18/12, at 2:00 p.m., Imaging/Recovery Room 2-110 door failed to latch shut.
3. On 6/18/12, at 2:40 p.m., Soiled Linen Room 2-149 self-closing door failed to latch shut.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that failed to positively latch during fire alarm testing, and by a fire door that was obstructed from closing. This deficient condition affected three of five floors in the Mission Viejo Tower 1 Building, and could result in the spread of fire or smoke in the event of a fire.

Findings:
During a tour of the facility with a staff member, the facility fire doors were observed during fire alarm testing.

Mission Viejo Tower 1
1. On 6/21/12, at 10:34 a.m., on the third floor, by Room #SICU-11, the fire/smoke doors released upon activation of the fire alarm system. The right hand door failed to positively latch when fully closed.
2. On 6/21/12, at 1:39 p.m., in the Basement, the fire door between Tower 1 and Tower 2 released upon activation if the fire alarm system. The right hand door failed to positively latch when fully closed.


27272

Tower I
1. On 6/21/12, at 12:45 p.m., the right leaf of smoke barrier door 37 on the Fourth floor could not be opened after it closed during fire alarm testing.

2. On 6/21/12, at 1:00 p.m., the left leaf of smoke barrier double door 38 on the Fourth floor was obstruted from closing by a chair, a cart and a computer.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by a fire door that failed to fully close and latch. This deficient condition affected one of five floors at the Mission Laguna Campus, and could result in the spread of smoke in the event of a fire.

Findings

Mission Laguna
On 6/20/12, at 10:05 a.m., Second floor Behavioral Health smoke barrier double door by the Consultation Room failed to fully close and latch shut.

Based on observation, the facility failed to maintain the exit access, as evidenced by an egress door with two locks that required a double action in order to open the door, and by obstructed exit doors. This could result in the delay of evacuation in the event of an emergency, and increase the risk of injury to patients, visitors and staff in affected smoke compartments. The deficient condition affected one of five floors in Tower I at the Mission Viejo campus.

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.

Findings:

During a tour of the facility with engineering staff, the exit doors were observed.

Tower I
1. On 6/19/12, at 1:45 p.m., the Nutritional Services Care Services Storeroom door 1-040
was equipped with two locks that required a double action to exit.
2. On 6/19/12, at 1:50 p.m., the Cafeteria double door right leaf was blocked by an Environmental Services trash bin.
3. On 6/19/12, at 2:00 p.m., the Linen Room secondary door 1-069 was blocked by a cart and boxes.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants when the hospital employee census was 2,190. This deficient condition affected all occupants in the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/18/12, the fire drill records were requested.

At 11:27 a.m., the records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drills were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill report, and did not represent a large portion of the 2,109 campus employees.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants. This deficient condition affected all occupants in the Mission Viejo Campus Tower 2 and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
18.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/18/12, at 11:27 a.m., the fire drill records were requested. The records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drill were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill but did not represent a large portion of campus employees.

Based on record review ans staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants when the hospital employee census was 328. This deficient condition affected all occupants in the Laguna Beach Campus, and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/20/12, at 3:17 p.m., the fire drill records were requested. The records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drills were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill, and did not represent a large portion of the 328 campus employees.

Based on document review, and staff interview, the facility failed to maintain the fire alarm system as evidenced by chimes and strobes that failed to function during fire alarm testing, and by the failure to provide a policy and procedure for the notification of staff and patients inside the operating rooms. This deficient condition affected four of eight smoke compartments in the Pavilion at Mission Viejo, and one of five floors in Tower I at the Mission Viejo Campus, and could result in the failure to notify building occupants in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
19.3.4.3 Notification.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1:* In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

Findings

During fire alarm testing with staff members on 6/21/12, the fire alarm system was observed.
1. 10:12 a.m., by Room #P-1226, the chime/strobe combination device was not audible. The area was in silence, and the alarm from the adjacent corridor could not be heard. Staff confirmed that the chime did not function.
2. At 10:13 a.m., across from Room #P-1258, the chime/strobe combination device was not audible. The strobe did function, but the chime was not audible.
3. At 10:29 a.m., in the East Mechanical Room, the chime/strobe combination device was not audible. The strobe did function, but the chime was not audible.
4. At 10:34 a.m., across from Room #P-1413, the chime/strobe combination device was not audible, and the strobe did not function.


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Findings:

During a tour of the facility with engineering staff, the notification devices were observed, and staff was interviewed.
Pavilion
1. On 6/21/12, at 10:15 a.m., Operating Room 3 was not equipped with an alarm, speaker or strobe. The alarm and speaker in the corridor could not be heard inside the Operating Room. The strobe could be seen in the corridor if staff were facing the front door entrance.
2. On 6/21/12, at 10:45 a.m., Operating Room 8 was not equipped with an alarm, speaker or strobe. During interview, staff stated that the alarms and speakers could not be heard inside the Operating Rooms, but that all Operating Room staff carried a two way communicator (walkie-talkie) and everyone was notified in a the surgery rooms during alarm testing and emergencies. Staff stated that a policy and procedure was in the process of being written. The Assistant Director stated that an internal page system was scheduled to be installed.
Tower I
1. On 6/21/12, at 1:20 p.m., the Second Floor Nursery had no speaker, no alarm, no strobe. The fire alarm and speaker could not be heard during fire alarm testing. During interview, staff stated that an alarm could not be heard. Staff carried a pager but no two way communication (walkie-talkie).

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by the failure of the smoke barrier doors to close on 1 of 4 floors during testing of the fire alarm system. This could result in the spread of smoke or fire, and increase the risk of injury to patients, visitors and staff in the affected smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
NFPA 72, National Fire Alarm Code, 1999 Edition
3-9.5.2 If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC systems smoke dampers, fire dampers, fan
control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
7-3.1 Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.

Mission Laguna
1. On 6/20/12, at 3:30 p.m., the smoke barrier doors on the first floor failed to release from the magnetic hold open devices during testing of the fire alarm system. The system was tested with the smoke detectors, and the the manual pull stations.
2. On 6/20/12, at 7:15 p.m., the surveyors were notified that the fire alarm system was repaired.
3. On 6/21/12, at 8:10 a.m., the fire alarm system was retested, and the six rated doors, two elevator doors, one separation door and three traffic doors affecting five smoke compartments were functioning.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the failure of a system based smoke detector to activate with aerosol smoke during fire alarm testing. This could result in delayed notification of smoke and fire and increase the risk of injury to patients, visitors and staff due to smoke and fire in the affected smoke compartments. This affected one of four floors in Tower II at the Mission Viejo Campus.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.
Tower II
On 6/21/12, at 11:00 a.m., the smoke detector SD 2-402 located on the fourth floor failed to activate after two attempts with aerosol smoke during fire alarm testing.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the failure of a system based smoke detector to activate with aerosol smoke during fire alarm testing. This could result in delayed notification of smoke and fire, and increase the risk of injury to patients, visitors and staff due to smoke and fire in the affected smoke compartments. This affected one of five floors at the Mission Laguna Campus.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.
Mission Laguna
On 6/20/12, at 3:45 p.m., the smoke detector located in the basement in front of the Auditorium failed to activate with aerosol smoke during fire alarm testing.

Based on interview and observation, the facility failed to ensure the valves for the automatic sprinkler are supervised, as evidenced by a tamper valve that failed to sound a local alarm when the valve was closed. This condition affected five of five floors, and could result in the failure of occupant notification in the event the valve is closed.

Findings:

During fire alarm testing with maintenance staff, on 6/20/12, the tamper valve for the automatic sprinkler system was observed.
Mission Laguna Beach
At 3:57 p.m., in the Basement, the tamper valve was closed. No audible or visual alarm was activated at the Fire Alarm Control Panel (FACP). The tamper valve was tested two more times, with no alarm at the FACP. When staff moved the toggle by hand, an audible and visual signal was received at the FACP. During review of the alarm activity sheet from the monitoring company, all signals were received including the three attempts of the tamper closure.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that were not maintained flush with the ceiling, shifted off to one side or were missing, and by sprinkler heads with a build-up of debris. This deficient condition affected eight of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the passage of smoke from one smoke compartment to another.

NFPA 25 (1998 Edition)
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 13, Installation of Sprinkler System, 1999 Edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

Findings:

During a tour of the facility with a staff member on 6/19/12, the automatic sprinkler system was observed.

1. At 9:59 a.m., in Cath Lab3 # P-1125, 1 of 4 sprinkler head escutcheons were missing. A two inch penetration was exposed in the ceiling surface.
2. At 10:10 a.m., in the Interventional Radiology Equipment Room by #P-150, there was less than the required 18 inch clearance provided. There was approximately 5 inches between the sprinkler head and the items stored on the shelves.
3. At 10:19 a.m., in Radiology 3 #P-185, two of two eschutcheons had a 1/2 inch penetration around the escutcheons.
4. At 10:22 a.m., in the EVS Room #P-1119, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.
5. At 10:38 a.m., in the Old Kitchen, 4 of 12 sprinkler head escutcheons had dropped off the ceiling surface by approximately one inch, and exposed two inch penetrations in the ceiling.
6. At 10:48 a.m., in the GI Lan /Endoscopy Clean Linen Room #P-1238, the sprinkler head escutcheon had dropped off the ceiling surface by approximately one inch, and exposed a two inch penetration in the ceiling.
7. At 10:52 a.m., in the Maintenance Room #P-1225, three of four sprinkler head escutcheons had dropped approximately one inch, and exposed two inch penetrations in the ceiling.
8. At 10:54 a.m., in the Laundry Room, one of two sprinkler heads had dropped approximately one inch, and exposed a two inch penetration in the ceiling.
9. At 11:21 a.m., in the Medtele Break Room #P-1350, three of five sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling.
10. At 11:23 a.m., in Room #P-138, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
11. At 11:24 a.m., in Room #P-137, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
12. At 11:25 a.m., in Room #P-136, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
13. At 11:29 a.m., in the Nourishment Room #P-1347, three of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
14. At 11:30 a.m., in Room #P-135, three of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
15. At 1:37 p.m., in the EVS Room #P-1324, the sprinkler head escutcheon had dropped off the ceiling surface by approximately one inch, and exposed a two inch penetration in the ceiling surface.


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Tower I
16. On 6/19/12, at 12:05 p.m., the Main Lobby had 12 of 12 fire sprinkler heads with a build-up of lint and debris.

Based on observation, the facility failed to maintain oxygen cylinders secured, as evidenced by one oxygen e-cylinder tank that was stored without being secured. This deficient practice affected one of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the acceleration of a fire.

NFPA 101 Life Safety Code, 2000 edition
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
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:
Pavilion
During a tour of the facility with a staff member on 6/19/12, in Radiology 2 Room #P-178, one of two oxygen E-cylinder tanks was stored free standing in a corner. Staff conformed that the tank had been stored free standing.

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of extension cords, and by the use of power strips for motorized equipment. This deficient condition affected three of five floors, and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with staff members on 6/20/2012, the electrical wiring in the facility was observed
Mission Viejo
1. At 9:25 a.m., on the 4th floor, in Office 21, there was an extension cord being used for computer equipment. The extension cord was plugged into a wall outlet, and ran over the ceiling tiles to the other side of the room.
2. At 9:29 a.m., on the 4th floor in Office 421, computer equipment was plugged into an extension cord instead of directly into the wall outlet.
3. At 10:20 a.m., on the 1st floor, in the South Coast Medical Center Center Storage/Break Room, a refrigerator was plugged into a power strip instead of directly into the wall outlet.
4. At 11:31 a.m., on the 2nd floor, in the Cardio Stress Lab, an extension cord was being used. The extension cord was plugged into a power strip.
5. At 11:47 a.m., on the 2nd floor, in the OR Recovery Room, two Work Stations on Wheels (WOWS) were plugged into two extension cords instead of directly into the wall outlet.


27272

Mission Laguna
On 6/20/12, at 10:30 a.m., the Second Floor Behavioral Health Intake Office had two multi-outlet adapters plugged into each other.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of surge protectors, and by an obstructed electrical panel. This deficient practice affected one of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with a staff member, the electrical wiring in the facility was observed.
1. On 6/19/12, at 10:36 a.m., in the Nursing Staffing Office Room #P-1205, two coffee makers and a microwave were plugged into a power strip instead of directly into the wall outlet.


27272

Tower I
1. On 6/18/12, at 3:30 p.m., the Staff Lounge 1-4104 had a toaster plugged into a surge protector, and not directly into the wall.
2. On 6/19/12, at 11:40 a.m., the Emergency Room Soiled Utility 1-142 had two multi-outlet adapters attached to the wall.
Pavilion
1. On 6/21/12, at 10:05 a.m., the Operating Room Lounge had an electrical panel blocked by a couch.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Laguna Beach Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Laguna Beach Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on observation, the facility failed to ensure the Alcohol Based Hand Dispensers were installed away from ignition sources as evidenced by Alcohol Based Hand Dispensers mounted over electrical sources. This could result in a fire and increase the risk of injury to patients, visitors and staff, and affected three of five floors in Tower I at the Mission Viejo Campus.

Findings:

During a tour of the facility with engineering staff, the Alcohol Based Hand Dispensers were observed.
Tower I
1. On 6/18/12, at 3:15 p.m., the Clean Supply Room 1-473 had an Alcohol Based Hand Dispenser mounted over the light switch.
2. On 6/19/12, at 10:40 a.m., Nurse Station 1-386 had an Alcohol Based Hand Dispenser mounted over an electrical outlet.
3. On 6/19/12, at 3:30 p.m., the Kitchen Office in the Basement had an Alcohol Based Hand Dispenser mounted over an electrical outlet.

Based on interview and observation, the facility failed to maintain their building free of penetrations, as evidenced by penetrations that had not been sealed. This condition affected the one of five floors at the Mission Laguna Beach campus, and could result in the passage of smoke from one part of the facility to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following
conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with maintenance staff, on 6/20/12, the facility walls and ceilings were observed.
Mission Laguna Beach
1. At 10:03 a.m., on the 1st floor in the Radiation Oncology Treatment Planning Office, there were two 2 inch penetrations on the bottom of the right hand wall.
2. At 10:34 a.m., on the 1st floor in the Pharmacy Storage Area, there was a 2 inch penetration around a duct that passed through a wall.
3. At 10:38 a.m., in materials Management, there was a 3 inch by 4 inch penetration in the sheetrock of the column near the entrance door.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by the failure to repair and seal penetrations in the walls and ceilings. This could result in the spread of smoke or fire from one smoke compartment to the next smoke compartment, and affected one of four floors in Tower I at the Mission Viejo Campus.

Findings:

During a tour of the facility with engineering staff, walls and ceilings were observed.
Tower I
On 6/19/12, at 10:10 a.m., Environmental Services Room 1-381 had an approximately 1/2 inch unsealed penetration in the upper left hand corner.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not latch, and by doors held open by magnets tied into the fire alarm system failed to release and fully close. This deficient condition affected three of five floors and had the potential to allow the migration of smoke or fire in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

Findings:

During a tour of the facility with a staff member on 6/20/12, the corridor doors were observed.
Mission Laguna Beach
1. At 9:33 a.m., on the 4th floor in Group Room 2 #423, the door was equipped with a self closing mechanism. When the door was held fully open and released, the door failed to positively latch when fully closed.
2. At 11:42 a.m., on the 2nd floor in Same Day Surgery Ambulatory Room 2, the doors were equipped with self closing mechanisms. The left hand door did not fully close and latch.
3. At 2:17 p.m., on the 4th floor room 401, the door released from the magnet when the fire alarm system was activated. The door remained fully open and failed to fully close and latch.
4. At 2:17 p.m., on the 4th floor room 401, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
5. At 2:17 p.m., on the 4th floor room 403, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
6. At 2:17 p.m., on the 4th floor room 406, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.
7. At 2:30 p.m., on the 3rd floor room 323, the door released from door magnet when the fire alarm system was activated. The door closed, but failed to positively latch.



27272

Mission Laguna
1. At 9:35 a.m., Patient Room 302 self-closing door failed to fully close and latch.
2. At 9:38 a.m., Patient Room 306 self-closing door failed to fully close and latch.
3. At 9:40 a.m., Patient Room 307 self-closing door failed to latch shut.
4. At 9:42 a.m., Third Floor ICU Supply Room self-closing door failed to latch shut.
5. At 9:44 a.m., Patient Room 321 self-closing door failed to latch shut.
6. At 9:48 a.m., Patient Room 355 self-closing door failed to fully close and latch shut.
7. At 9:52 a.m., Clean Utility Storage across from Patient Room 306 self-closing door failed to fully close and latch shut.
8. At 11:20 a.m., Second floor Entrance door to Emergency Room by Treatment Room 2 failed to latch shut.
9. At 11:25 a.m., Emergency Room 9 door was blocked from closing by a chair.
10. At 11:27 a.m., Emergency Room 10 door was blocked from closing by a chair.
11. At 11:35 a.m., Radiology Dressing Room door failed to latch shut.
12. At 11:40 a.m., X-Ray Room 6 door failed to latch shut.
13. At 11:50 a.m., Dexa Bone Density Room door failed to fully close and latch shut.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that did not properly latch and by doors that were impeded from closing. This affected one of five floors in Tower I, and one of one floor in the Pavilion, at the Mission Viejo Campus and could result in the migration of fire or smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.
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.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Findings:

During a tour of the facility with a staff member, the corridor doors were observed.
Mission Viejo - Pavilion
1. On 6/19/12, at 11:06 a.m., in the Clean Linen Room # P-1319, the door was equipped with a self closing mechanism. When the door was opened to the full extent and released, the door failed to positively latch.
2. On 6/19/12, at 11:08 a.m., the door to Room #P-141 was equipped with a self closing mechanism. The door was held open with a door wedge. When the door was opened to the full extent and released, the door failed to positively latch.
3. On 6/19/12, at 11:12 a.m., the door to Room #P-140 was equipped with a self closing mechanism. The door was held open with a chair propped up against the door. When the door was opened to the full extent and released, the door failed to positively latch.
4. On 6/19/12, at 11:1308 a.m., the door to Room #P-139 was equipped with a self closing mechanism. The door was held open with an isolation cart that was propped up against the door. When the door was opened to the full extent and released, the door failed to positively latch.
5. On 6/19/12, at 11:21 a.m., in the Medtele Break Room #P-1350, the door was equipped with a self closing mechanism. When the door was opened to the full extent and released, the door failed to positively latch.
6. On 6/19/12, at 11:49 a.m., in the Nuclear Medicine2 Room #P-165, the door was obstructed from closing by the bed in the room.
7. On 6/19/12, at 1:39 p.m., in Room #P-151, the door was held open by a trash can.
8. On 6/19/12, at 1:42 p.m., in Room #P-154, the door was held open by a trash can.
9. On 6/19/12, at 1:40 p.m., in Room #P-1405, the door was equipped with a self closing mechanism, and the door was held open by a trash can.



27272

Tower I
1. On 6/19/12, at 10:15 a.m., Patient Room 1-308 door was difficult to open when shut.
2. On 6/19/12, at 10:30 a.m., Clinical Work Station Room 1-399 self-closing door failed to fully close and latch.
3. On 6/19/12, at 11:50 a.m., Emergency Exam Room 1-106 door failed to latch.
4. On 6/19/12, at 11:55 a.m., Emergency Exam Room 1-105 door failed to latch.
5. On 6/19/12, at 2:10 p.m., Pharmacy Office 1-080 self-closing door failed to latch.

Pavilion
1. On 6/21/12, at 10:10 a.m., Operating Rooms Environmental Services Room double door failed to latch.
2. On 6/21/12, at 10:17 a.m., Operating Room 3 secondary door was equipped with a roller latch.
3. On 6/21/12, at 10:20 a.m., Operating Room 8 double door failed to latch.
4. On 6/21/12, at 10:28 a.m., Operating Room 4 secondary door was equipped with a roller latch.

Based on observation, the facility failed to maintain corridor doors as evidenced by a corridor doors that failed to close and latch when tested. This affected one of four floors at the Mission Viejo Campus, and could result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with a staff member, the corridor doors were observed.
Tower II
1. On 6/18/12, at 1:40 p.m., Linen Room 2-464 self-closing door failed to fully close and latch shut.
2. On 6/18/12, at 2:00 p.m., Imaging/Recovery Room 2-110 door failed to latch shut.
3. On 6/18/12, at 2:40 p.m., Soiled Linen Room 2-149 self-closing door failed to latch shut.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by fire doors that failed to positively latch during fire alarm testing, and by a fire door that was obstructed from closing. This deficient condition affected three of five floors in the Mission Viejo Tower 1 Building, and could result in the spread of fire or smoke in the event of a fire.

Findings:
During a tour of the facility with a staff member, the facility fire doors were observed during fire alarm testing.

Mission Viejo Tower 1
1. On 6/21/12, at 10:34 a.m., on the third floor, by Room #SICU-11, the fire/smoke doors released upon activation of the fire alarm system. The right hand door failed to positively latch when fully closed.
2. On 6/21/12, at 1:39 p.m., in the Basement, the fire door between Tower 1 and Tower 2 released upon activation if the fire alarm system. The right hand door failed to positively latch when fully closed.


27272

Tower I
1. On 6/21/12, at 12:45 p.m., the right leaf of smoke barrier door 37 on the Fourth floor could not be opened after it closed during fire alarm testing.

2. On 6/21/12, at 1:00 p.m., the left leaf of smoke barrier double door 38 on the Fourth floor was obstruted from closing by a chair, a cart and a computer.

Based on observation and interview, the facility failed to maintain fire doors as evidenced by a fire door that failed to fully close and latch. This deficient condition affected one of five floors at the Mission Laguna Campus, and could result in the spread of smoke in the event of a fire.

Findings

Mission Laguna
On 6/20/12, at 10:05 a.m., Second floor Behavioral Health smoke barrier double door by the Consultation Room failed to fully close and latch shut.

Based on observation, the facility failed to maintain the exit access, as evidenced by an egress door with two locks that required a double action in order to open the door, and by obstructed exit doors. This could result in the delay of evacuation in the event of an emergency, and increase the risk of injury to patients, visitors and staff in affected smoke compartments. The deficient condition affected one of five floors in Tower I at the Mission Viejo campus.

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.

Findings:

During a tour of the facility with engineering staff, the exit doors were observed.

Tower I
1. On 6/19/12, at 1:45 p.m., the Nutritional Services Care Services Storeroom door 1-040
was equipped with two locks that required a double action to exit.
2. On 6/19/12, at 1:50 p.m., the Cafeteria double door right leaf was blocked by an Environmental Services trash bin.
3. On 6/19/12, at 2:00 p.m., the Linen Room secondary door 1-069 was blocked by a cart and boxes.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants when the hospital employee census was 2,190. This deficient condition affected all occupants in the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/18/12, the fire drill records were requested.

At 11:27 a.m., the records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drills were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill report, and did not represent a large portion of the 2,109 campus employees.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants. This deficient condition affected all occupants in the Mission Viejo Campus Tower 2 and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
18.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/18/12, at 11:27 a.m., the fire drill records were requested. The records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drill were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill but did not represent a large portion of campus employees.

Based on record review ans staff interview, the facility failed to conduct quarterly fire drills to include all staff members. This deficient was evidenced by fire drills conducted with 12 to 43 participants when the hospital employee census was 328. This deficient condition affected all occupants in the Laguna Beach Campus, and could result in the lack of staff knowledge in the event of a fire or emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During document review on 6/20/12, at 3:17 p.m., the fire drill records were requested. The records provided had a limited number of participant signatures. When asked about the numbers, staff stated that fire drills were performed with the area affected, and the adjacent unit. Staff in other parts of the building participated but did not report concerns, issues or a summary report of staff response. Fire drills were performed one per shift per quarter, only contained 12 to 43 signatures per fire drill, and did not represent a large portion of the 328 campus employees.

Based on document review, and staff interview, the facility failed to maintain the fire alarm system as evidenced by chimes and strobes that failed to function during fire alarm testing, and by the failure to provide a policy and procedure for the notification of staff and patients inside the operating rooms. This deficient condition affected four of eight smoke compartments in the Pavilion at Mission Viejo, and one of five floors in Tower I at the Mission Viejo Campus, and could result in the failure to notify building occupants in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
19.3.4.3 Notification.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1:* In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

Findings

During fire alarm testing with staff members on 6/21/12, the fire alarm system was observed.
1. 10:12 a.m., by Room #P-1226, the chime/strobe combination device was not audible. The area was in silence, and the alarm from the adjacent corridor could not be heard. Staff confirmed that the chime did not function.
2. At 10:13 a.m., across from Room #P-1258, the chime/strobe combination device was not audible. The strobe did function, but the chime was not audible.
3. At 10:29 a.m., in the East Mechanical Room, the chime/strobe combination device was not audible. The strobe did function, but the chime was not audible.
4. At 10:34 a.m., across from Room #P-1413, the chime/strobe combination device was not audible, and the strobe did not function.


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Findings:

During a tour of the facility with engineering staff, the notification devices were observed, and staff was interviewed.
Pavilion
1. On 6/21/12, at 10:15 a.m., Operating Room 3 was not equipped with an alarm, speaker or strobe. The alarm and speaker in the corridor could not be heard inside the Operating Room. The strobe could be seen in the corridor if staff were facing the front door entrance.
2. On 6/21/12, at 10:45 a.m., Operating Room 8 was not equipped with an alarm, speaker or strobe. During interview, staff stated that the alarms and speakers could not be heard inside the Operating Rooms, but that all Operating Room staff carried a two way communicator (walkie-talkie) and everyone was notified in a the surgery rooms during alarm testing and emergencies. Staff stated that a policy and procedure was in the process of being written. The Assistant Director stated that an internal page system was scheduled to be installed.
Tower I
1. On 6/21/12, at 1:20 p.m., the Second Floor Nursery had no speaker, no alarm, no strobe. The fire alarm and speaker could not be heard during fire alarm testing. During interview, staff stated that an alarm could not be heard. Staff carried a pager but no two way communication (walkie-talkie).

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by the failure of the smoke barrier doors to close on 1 of 4 floors during testing of the fire alarm system. This could result in the spread of smoke or fire, and increase the risk of injury to patients, visitors and staff in the affected smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
NFPA 72, National Fire Alarm Code, 1999 Edition
3-9.5.2 If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of HVAC systems smoke dampers, fire dampers, fan
control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
7-3.1 Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.

Mission Laguna
1. On 6/20/12, at 3:30 p.m., the smoke barrier doors on the first floor failed to release from the magnetic hold open devices during testing of the fire alarm system. The system was tested with the smoke detectors, and the the manual pull stations.
2. On 6/20/12, at 7:15 p.m., the surveyors were notified that the fire alarm system was repaired.
3. On 6/21/12, at 8:10 a.m., the fire alarm system was retested, and the six rated doors, two elevator doors, one separation door and three traffic doors affecting five smoke compartments were functioning.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the failure of a system based smoke detector to activate with aerosol smoke during fire alarm testing. This could result in delayed notification of smoke and fire and increase the risk of injury to patients, visitors and staff due to smoke and fire in the affected smoke compartments. This affected one of four floors in Tower II at the Mission Viejo Campus.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.
Tower II
On 6/21/12, at 11:00 a.m., the smoke detector SD 2-402 located on the fourth floor failed to activate after two attempts with aerosol smoke during fire alarm testing.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the failure of a system based smoke detector to activate with aerosol smoke during fire alarm testing. This could result in delayed notification of smoke and fire, and increase the risk of injury to patients, visitors and staff due to smoke and fire in the affected smoke compartments. This affected one of five floors at the Mission Laguna Campus.

Findings:

During a tour of the facility with engineering staff, the fire alarm devices were observed and tested.
Mission Laguna
On 6/20/12, at 3:45 p.m., the smoke detector located in the basement in front of the Auditorium failed to activate with aerosol smoke during fire alarm testing.

Based on interview and observation, the facility failed to ensure the valves for the automatic sprinkler are supervised, as evidenced by a tamper valve that failed to sound a local alarm when the valve was closed. This condition affected five of five floors, and could result in the failure of occupant notification in the event the valve is closed.

Findings:

During fire alarm testing with maintenance staff, on 6/20/12, the tamper valve for the automatic sprinkler system was observed.
Mission Laguna Beach
At 3:57 p.m., in the Basement, the tamper valve was closed. No audible or visual alarm was activated at the Fire Alarm Control Panel (FACP). The tamper valve was tested two more times, with no alarm at the FACP. When staff moved the toggle by hand, an audible and visual signal was received at the FACP. During review of the alarm activity sheet from the monitoring company, all signals were received including the three attempts of the tamper closure.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by sprinkler head escutcheons that were not maintained flush with the ceiling, shifted off to one side or were missing, and by sprinkler heads with a build-up of debris. This deficient condition affected eight of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the passage of smoke from one smoke compartment to another.

NFPA 25 (1998 Edition)
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 13, Installation of Sprinkler System, 1999 Edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

Findings:

During a tour of the facility with a staff member on 6/19/12, the automatic sprinkler system was observed.

1. At 9:59 a.m., in Cath Lab3 # P-1125, 1 of 4 sprinkler head escutcheons were missing. A two inch penetration was exposed in the ceiling surface.
2. At 10:10 a.m., in the Interventional Radiology Equipment Room by #P-150, there was less than the required 18 inch clearance provided. There was approximately 5 inches between the sprinkler head and the items stored on the shelves.
3. At 10:19 a.m., in Radiology 3 #P-185, two of two eschutcheons had a 1/2 inch penetration around the escutcheons.
4. At 10:22 a.m., in the EVS Room #P-1119, the sprinkler head escutcheon had dropped off the ceiling surface approximately one inch, and exposed a two inch penetration in the ceiling.
5. At 10:38 a.m., in the Old Kitchen, 4 of 12 sprinkler head escutcheons had dropped off the ceiling surface by approximately one inch, and exposed two inch penetrations in the ceiling.
6. At 10:48 a.m., in the GI Lan /Endoscopy Clean Linen Room #P-1238, the sprinkler head escutcheon had dropped off the ceiling surface by approximately one inch, and exposed a two inch penetration in the ceiling.
7. At 10:52 a.m., in the Maintenance Room #P-1225, three of four sprinkler head escutcheons had dropped approximately one inch, and exposed two inch penetrations in the ceiling.
8. At 10:54 a.m., in the Laundry Room, one of two sprinkler heads had dropped approximately one inch, and exposed a two inch penetration in the ceiling.
9. At 11:21 a.m., in the Medtele Break Room #P-1350, three of five sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling.
10. At 11:23 a.m., in Room #P-138, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
11. At 11:24 a.m., in Room #P-137, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
12. At 11:25 a.m., in Room #P-136, two of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
13. At 11:29 a.m., in the Nourishment Room #P-1347, three of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
14. At 11:30 a.m., in Room #P-135, three of three sprinkler heads had dropped off the ceiling surface, and exposed a two inch penetration in the ceiling surface.
15. At 1:37 p.m., in the EVS Room #P-1324, the sprinkler head escutcheon had dropped off the ceiling surface by approximately one inch, and exposed a two inch penetration in the ceiling surface.


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Tower I
16. On 6/19/12, at 12:05 p.m., the Main Lobby had 12 of 12 fire sprinkler heads with a build-up of lint and debris.

Based on observation, the facility failed to maintain oxygen cylinders secured, as evidenced by one oxygen e-cylinder tank that was stored without being secured. This deficient practice affected one of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the acceleration of a fire.

NFPA 101 Life Safety Code, 2000 edition
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
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:
Pavilion
During a tour of the facility with a staff member on 6/19/12, in Radiology 2 Room #P-178, one of two oxygen E-cylinder tanks was stored free standing in a corner. Staff conformed that the tank had been stored free standing.

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of extension cords, and by the use of power strips for motorized equipment. This deficient condition affected three of five floors, and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with staff members on 6/20/2012, the electrical wiring in the facility was observed
Mission Viejo
1. At 9:25 a.m., on the 4th floor, in Office 21, there was an extension cord being used for computer equipment. The extension cord was plugged into a wall outlet, and ran over the ceiling tiles to the other side of the room.
2. At 9:29 a.m., on the 4th floor in Office 421, computer equipment was plugged into an extension cord instead of directly into the wall outlet.
3. At 10:20 a.m., on the 1st floor, in the South Coast Medical Center Center Storage/Break Room, a refrigerator was plugged into a power strip instead of directly into the wall outlet.
4. At 11:31 a.m., on the 2nd floor, in the Cardio Stress Lab, an extension cord was being used. The extension cord was plugged into a power strip.
5. At 11:47 a.m., on the 2nd floor, in the OR Recovery Room, two Work Stations on Wheels (WOWS) were plugged into two extension cords instead of directly into the wall outlet.


27272

Mission Laguna
On 6/20/12, at 10:30 a.m., the Second Floor Behavioral Health Intake Office had two multi-outlet adapters plugged into each other.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of surge protectors, and by an obstructed electrical panel. This deficient practice affected one of eight smoke compartments in the Mission Viejo Pavilion Building, and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with a staff member, the electrical wiring in the facility was observed.
1. On 6/19/12, at 10:36 a.m., in the Nursing Staffing Office Room #P-1205, two coffee makers and a microwave were plugged into a power strip instead of directly into the wall outlet.


27272

Tower I
1. On 6/18/12, at 3:30 p.m., the Staff Lounge 1-4104 had a toaster plugged into a surge protector, and not directly into the wall.
2. On 6/19/12, at 11:40 a.m., the Emergency Room Soiled Utility 1-142 had two multi-outlet adapters attached to the wall.
Pavilion
1. On 6/21/12, at 10:05 a.m., the Operating Room Lounge had an electrical panel blocked by a couch.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Laguna Beach Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the automatic sprinkler system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Findings:

During document review with staff members on 6/20/12, 3:30 p.m., the fire watch plan for the automatic sprinkler system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Laguna Beach Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.

Based on document review and staff interview, the facility failed to maintain a designated fire watch plan in the event the fire alarm system were to fail or be out of service for more than four hours in a twenty-four hour period. This deficient condition affected all building occupants at the Mission Viejo Campus, and could result in the lack of staff knowledge in the event of a system failure.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff members on 6/20/12, the fire watch plan for the fire alarm system was requested. The Fire Watch Policy provided did not indicate the authority having jurisdiction to be contacted, and did not provide the policy for staff to follow in the event a fire watch was to be implemented.