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Cooking Facilities

Tag No.: K0324

Based on observations and interview with the director of maintenance (DOM) during the tour of the facility, the facility failed to maintain the kitchen hood system in accordance with NFPA 101 (2012 edition).

The findings included:

On 12/18/19 between 1:45 AM and 5:00 PM, during the facility tour with the DOM it was observed that:
1) the kitchen hood joints and seams were not properly sealed in the main hood and grill hood.
2) the gas fed equipment mounted on casters were not tethered to the wall / floor under the main hood system.
An interview was conducted with the DOM concurrent with the observations and confirmed the findings.

Per NFPA 101 (2012 edition) 19.3.2.5
Per NFPA 96 (2011 edition) 5.1.4

Per NFPA 101 (2012 edition) 19.3.2.5, 9.2.3
per NFPA 96 (2011 edition) 12.1.2.2
per NFPA 54 (2012 edition) 9.6.1.2

Interior Wall and Ceiling Finish

Tag No.: K0331

Based on observations and interview with the director of maintenance (DOM) during the tour of the facility, the facility failed to protect Interior wall finishes in accordance to NFPA 101 (2012 edition).

Findings included:

On 12/19/19 between 11:30 AM and 12:45 PM during the facility tour with DOM, it was observed that the storage room at the Recovery Center displayed flammable material (fiber board) installed floor to ceiling on 3 of 3 walls. In an interview, the DOM acknowledged concurrent with the findings.

per NFPA 101 (2012 edition) Chapter(s) 19.3.3.2, 10.2, 10.2.1.1

Sprinkler System - Maintenance and Testing

Tag No.: K0353

Based on observations during the tour of the facility and interview with the director of maintenance (DOM), the facility failed to maintain the fire protection sprinkler system (FPSS) in accordance with NFPA 101 (2012 edition) and NFPA 25 (2011 edition).

The findings included:

On 12/18/19 between 1:45 PM and 5:00 PM, during the tour of the Hospital facility with the DOM, it was observed dusty ceiling pendant sprinklers heads in rooms 234, 228, 222, 220, main kitchen walkin cooler and freezer. In an interview, the DOM acknowledged concurrent with the findings.

per NFPA 101 (2012 edition) 9.11, 9.11.1
per NFPA 25 (2011 edition) 5.2.1.1.1, 5.2.1.1.2 (2)

On 12/19/19 between 9:00 AM and 11:00 AM, during the tour of the Hospital facility with DOM, it was revealed that the facility failed to maintain the fire protection backflow physical operation of the appliance. The appliance displayed the outside stems and tamper switch arms were painted and stuck together. An interview was conducted with the DOM concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 edition) Chapter 19.7.6, 4.6.12
per NFPA 25 (2011 edition) Chapter 13.6, 13.6.3