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Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by the failure of two Inspector's Test Valves (ITVs), by an ongoing trouble condition related to a notification appliance circuit, and by a delay in activation of life safety functions such as fire door release. This was also evidenced fire alarm cables that were not supported by building structures or protected against damage. This affected one of six floors in the Pavilion, seven of seven floors in the Tower, single story building, two of two smoke compartments in the basement of Van Nuys, and seven of seven floors in the Hollywood building. This could result in a delay in notification and response, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

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.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.4.1.2 The time delay between the activation of an initiating device and the automatic activation of a local fire safety function shall not exceed 20 seconds.
Effective on January 1, 2002, the time delay between the activation of an initiating device and the automatic activation of a local fire safety function shall not exceed 10 seconds.

1-5.4.6 Trouble Signals. Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

1-5.5.4 Wiring. The installation of all wiring, cable, and equipment shall be in accordance with NFPA 70, National Electrical Code, and specifically with Articles 760, 770, and 800, where applicable. Optical fiber cables shall be protected against mechanical injury in accordance with Article 760.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

3-2.2 Signal Annunciation. Protected premises fire alarm systems shall be arranged to annunciate alarm, supervisory, and trouble signals in accordance with 1-5.7.

NFPA 70, National Electrical Code, 1999 Edition
Article 760 - Fire Alarm Systems
760-8 Mechanical Execution of Work. Fire alarm circuits shall be installed in a neat workmanlike manner. Cables shall be supported by the building structure in such a manner that the cable will not be damaged by normal building use.

Findings:

During a facility tour with staff from 7/26/16 to 7/28/16, the fire alarm systems were tested and records were reviewed. The Pavilion, Tower, and Single Story Building shared the same fire alarm system.

Tower and Single Story Building:

1. At 10:57 a.m., on 7/26/16, the ITV on the first floor, next to the tunnel elevators, was tested by the fire alarm vendor (F.A. Tech1). After 45 seconds, a local alarm at the security office's fire panel was observed but the facility-wide fire alarm notification devices did not activate.

At 10:57 a.m., the ITV by the tunnel elevators was tested again and allowed to flow for more than 90 seconds. The fire alarm notification devices did not activate throughout the building.

At 11:05 a.m., the ITV on the east side of the Single Story Building was tested by F.A. Tech1. After 54 seconds, a local alarm at the fire panel was received and the exterior sprinkler bell alarmed. The facility-wide fire alarm notification devices were not activated and no alarms could be heard inside the building.

During an interview at 2:44 p.m., F.A. Tech1 stated that the "correlation" between the ITVs and the notification devices in the fire alarm system's computer program was turned off accidentally since the system was last tested a few days before.

The System Events Report from the monitoring company showed that the fire alarm system was tested on 7/21/16.

Pavilion
Third Floor:

2. At 4:33 p.m., on 7/26/16, the System Events Report showing all fire alarm system activities was provided for June and July 2016. The report showed that the panel exhibited an ongoing trouble almost daily since 6/2/16. The "PAV 3RD STROBE RELAY" trouble condition was exhibited during 24 of 30 days in June and 21 of 31 days in July. On 7/22/16, 7/21/16, 7/20/16, 7/18/16, 7/7/16, 7/6/16/, 7/5/16, and 7/2/16, this trouble signal activated intermittently throughout the whole day. On 6/30/16, 6/28/16, 6/27/16, 6/25/16, 6/22/16, 6/19/16, and 6/4/16, this trouble signal activated intermittently throughout the whole day.

During an interview at 10:26 a.m., on 7/28/16, F.A. Tech1 stated that the source of the trouble signal was a loose wire in the fire alarm subpanel on the third floor. He stated that all the strobes on the third floor Pavilion would have potentially been affected if the trouble was not addressed.

Van Nuys
Basement:

3. At 9:19 a.m., on 7/27/16, the pull station near the elevator was activated by the Director of Facilities (DFS3). The smoke barrier doors in the basement failed to release from their hold open device until the fire alarm system was reset. The same pull station was tested again at 9:21 a.m. and the fire alarm notification devices in the basement did not activate and the smoke barrier doors did not release. The pull station was tested for a third time at 9:27 a.m. and the smoke barrier doors did not release until the fire alarm system was reset.

At 9:29 a.m., the smoke detector near the smoke barrier doors in the basement was tested by DFS3 and the fire alarm system remained active for more than 40 seconds. The smoke barrier doors failed to release from their magnetic hold open devices until the fire alarm system was reset.


On 7/28/16, an invoice from a vendor stated that wires to the door holder circuit were connected incorrectly at the fire alarm panel and were repaired.

Hollywood
Basement:

4. At 2:55 p.m., on 7/27/16, the main fire alarm panel in the radiology department was observed. There were two communication cables running through the panel door and approximately 5 feet across the room to a phone jack below a desk. The cables were not protected or permanently attached to the wall.

During an interview at 2:56 p.m., the Chief Engineer (CE1) stated that those cables connected the fire alarm system to the remote monitoring company.

















29566

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler systems. This was evidenced by an ongoing sprinkler head replacement project awaiting approval by the Office of Statewide Health Planning and Development (OSHPD). This was also evidenced by a leaking outside screw and yoke (OS&Y) valve. This affected the entire Culver City Campus and two of two floors in the Van Nuys building. This could result in a delay in extinguishing a fire and could result in the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2-3.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals.
Exception No. 1: Sprinklers manufactured prior to 1920 shall be replaced.
Exception No. 2: Sprinklers manufactured using fast response elements that have been in service for 20 years shall be tested. They shall be retested at 10-year intervals.
Exception No. 3: Representative samples of solder-type sprinklers with a temperature classification of extra high [325°F (163°C)] or greater that are exposed to semicontinuous to continuous maximum allowable ambient temperature conditions shall be tested at 5-year intervals.
Exception No. 4: Where sprinklers have been in service for 75 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to
the authority having jurisdiction for field service testing. Test procedures shall be repeated at 5-year intervals.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

Findings:

During a facility tour with staff from 7/26/16 to 7/28/16, the sprinkler system was observed and records were reviewed.

Culver City Campus:

1. During the previous Life Safety Code revisit survey on 4/8/16, the facility was cited for the failure to replace recalled sprinkler heads.

At 9:00 a.m., on 7/26/16, records showed that the facility obtained an OSHPD permit (S160548-19-00) to begin replacement of the sprinkler heads. Invoices and Inspector of Record (IOR) reports showed that all 1155 recalled sprinkler heads were replaced as of 7/20/16. The work had not yet been inspected or approved by OSHPD.

During an interview at 9:32 a.m., the Director of Facilities (DFS1) stated that the project will not be closed out until an additional 1500 heads, that are approaching 50 years of age, are replaced.

Van Nuys
Basement:

2. At 9:32 a.m., on 7/27/16, the OS&Y valve at the riser was turned by the Director of Facilities (DFS3) and the valve leaked at the stem. The valve was turned again at 9:34 a.m. and it still leaked at the stem.














29566

Based on record review and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) system. This was evidenced by the use of temporary air handler as part of an HVAC restoration project. that was unsecured in a public parking lot without approval from the authority having jurisdiction (AHJ). This affected the Van Nuys Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.

Findings:

During a facility tour with staff from 7/26/16 to 7/28/16, the HVAC systems were observed and records were reviewed.

Van Nuys:

1. During a previous Life Safety Code revisit survey on 4/8/16, the facility was cited for using a temporary air handler in the west parking lot without a permit from the Office of Statewide of Health Planning and Development (OSHPD). The air handler was portable and not secured. The facility was working on obtaining OSHPD approval for the temporary air handler during the HVAC restoration project.

At 9:15 a.m., on 7/26/16, Inspector of Record (IOR) reports and pictures showed that the temporary air handler was moved to the roof and seismically anchored on 6/8/16. The facility was issued an emergency permit (S161033-19-00) to use the temporary air handler while the HVAC restoration project (S152795-19-00) is getting approved.

During an interview on at 8:30 a.m., on 7/27/16, the Project Manager (PM1) stated that the facility was still using the temporary air handler and are waiting to get a permit to begin work on Project S152795-19-00.







29566

Based on record review, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of an emergency oxygen supply connection. This affected the patients in the Pavilion. This could result in the delay in emergency response upon failure of the piped-in system.

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, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 7/26/16 to 7/28/16, the piped-in medical gas system was observed.

Pavilion:

1. During a previous Life Safety Code revisit survey on 4/8/16, the facility was previously cited because the cryogenic system was not equipped with an emergency oxygen supply connection (oxygen autofill port).

At 9:20 a.m., on 7/26/16, records provided by the Vice President of Facilities (VPFS1) and the Director of Facilities (DFS1) showed that the application for Project S160471-19-00 was submitted to, but not yet approved by, the Office of Statewide Health Planning and Development (OSHPD).

Based on observation, record review, and interview, the facility failed to ensure that equipment was safely installed in accordance with manufacturer's specifications and approved by the authority having jurisdiction (AHJ). This was evidenced by medication dispensers that were not seismically anchored in accordance with manufacturer's specifications and were not approved by the Office of Statewide Health Planning and Development (OSHPD). This affected the basement of the Hollywood Building and one of six floors in the Pavilion. This could result in the increased risk of injury in the event of an earthquake.

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.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 9 Manufacturer Requirements
9-1 Scope. This chapter covers the performance, maintenance, and testing, with regard to safety, required of manufacturers of equipment used within health care facilities.

9-2.1.1.2 Mechanical Stability. The appliance shall be mechanically stable in the position of normal use. If the appliance is intended for use in an anesthetizing location, 12-4.1 applies.

Findings:

During a facility tour with staff from 7/26/16 to 7/28/16, the medication dispensers were observed.

Pavilion and Hollywood:

1. During a previous Life Safety Code revisit survey on 4/8/16, the facility was previously cited because the medication cabinets were not seismically anchored in accordance with the manufacturer's specifications. The facility was working to anchor the medication cabinets under OSHPD Projects S161365-19-00 (Hollywood) and S161358-19-00 (Pavilion).

At 9:23 a.m., on 7/26/16, records provided by the Director of Facilities (DFS1) indicated that the above OSHPD projects were still awaiting approval. DFS1 provided the manufacturer's specifications for the seismic straps used as an interim safety measure.

At 2:59 p.m., on 7/27/16, the medication cabinet across from the bed in the surgical recovery room at Hollywood was temporarily strapped to the wall using industrial Velcro straps.

At 9:33 a.m.,the medication cabinet in the Open Unit of the sixth floor in Pavilion was temporarily strapped to the wall using industrial Velcro straps.
During an interview at 9:34 a.m., DFS1 stated that all the medication cabinets throughout the Pavilion and Hollywood have been temporarily strapped until OSHPD approves the projects for anchoring.









29566

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by generators that were not monitored by remote alarm annunciators. This affected the entire Culver City Campus and the Van Nuys building. This could result in a delay in identifying problems with the generator and the increased risk of generator failure, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 70 , National Electrical Code, 1999 Edition
700-12 The annunciator shall indicate alarm condition of the emergency or auxiliary power source as follows:
(a)Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b)Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
1-1.3 This standard covers installation, maintenance, operation, and testing requirements as they pertain to the performance of the emergency power supply system (EPSS).

3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

Findings:

During a facility tour with staff on 7/26/16 to 7/28/16, the facility generators were observed.

Culver City Campus and Van Nuys:

1. During a previous Life Safety Code revisit survey on 4/8/16, the facility was previously cited because the three generators at the Culver City Campus, and the generator at Van Nuys, were not monitored by remote alarm annunciators.

At 9:20 a.m., on 7/26/16, records provided by the Vice President of Facilities (VPFS1) and the Director of Facilities (DFS1) showed that the application for Project S160471-19-00 was submitted to, but not yet approved by, the Office of Statewide Health Planning and Development (OSHPD). This project also encompassed the installation of the oxygen fill port cited in K77. The facility also obtained a permit for Project S160564-19-00 on 5/25/16 and began annunciator panel installation at Van Nuys.

At 8:24 a.m., on 7/27/16, the most recent Inspector of Record (IOR) report for the Van Nuys installation was dated 7/19/16 and indicated that conduits have been installed to run the lines to an annunciator panel at Nurses Station.

During an interview at 8:25 a.m., DFS3 stated that the annunciator has not yet been installed but the work is ongoing.









29566