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Based on document review, the facility failed to maintain the battery back-up emergency lighting. This was evidenced by no monthly testing of the battery back-up emergency lighting unit. This affected the building and could result in a delayed evacuation due to limited exit sign or egress visibility.

NFPA 101 Life Safety Code, 2012 edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11?2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 1 1/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During document review and interview with the Senior Program Manager on 8/23/17, the battery back-up emergency lighting was observed, and documents were requested.

At 1:44 p.m., the facility failed to provide documentation for the 30 seconds monthly testing of the emergency lighting unit. The finding was acknowledged by the Senior Program Manager.

Based on document review and interview, the facility failed to provide a written protocol to ensure that if the fire system was out of service for more than four hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by incomplete documentation. This could result in the AHJ being unable to exercise oversight in the event of a fire alarm system disruption in service. This affected the Acute Psych Unit on the second floor.

Findings:

During document review and interview with the Senior Program Manager on 8/23/17, the fire alarm system fire watch policy was reviewed.

At 2:09 p.m., the documentation provided for an approved fire watch for the fire alarm system did not include guidance for the notification of the California Department of Public Health (CDPH) if the fire alarm system was out of service for more than four hours in a 24 hour period. During an interview, the Senior Program Manager confirmed the finding and stated that they would update their fire watch policy.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by failing to complete monthly visual inspections of components to the sprinkler system, and by the failure to provide an annual test, and a five year maintenance, test, and inspection for the sprinkler system. This could affect the operation of the sprinkler system that could result in delay in extinguishing a fire, resulting in injury to residents. This affected the Acute Psych Unit on the second floor.

NFPA 101, Life Safety Code, 2012 Edition
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.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
Chapter 5 Sprinkler Systems.
4.3 Records.
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.

5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

5.2.1.1.6* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

5.2.1.1.7 Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.2.1.3 Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected.

5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.

5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow
alarm and supervisory alarm devices shall be inspected quarterly
to verify that they are free of physical damage.


5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.
5.3.3.2* Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

8.3.3 Annual Flow Testing.
8.3.3.1* An annual test of each pump assembly shall be conducted by qualified personnel under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices.
8.3.3.1.1 If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be permitted to operate at maximum allowable discharge.
8.3.3.1.2* The annual test shall be conducted as described in 8.3.3.1.2.1, 8.3.3.1.2.2, or 8.3.3.1.2.3.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Findings:

During document review, and interview with the Senior Program Manager on 8/23/17, the sprinkler system's testing and inspection records were reviewed, and staff was interviewed.

1. At 2:30 p.m., the testing and inspection records provided for the wet pipe sprinkler system, failed to include January, February, April, June, July of 2017; and September, November, and December of 2016 for monthly visual inspections of the gauges and control valves. The monthly visual inspections of components to the wet pipe sprinkler system were conducted during the sprinkler quarterly tests.

2. At 2:33 p.m., the facility failed to provide documentation for the annual maintenance, test, and inspection report for the sprinkler system, and report for the five year certification for the sprinkler system. The last five year certification for the sprinkler system was on 7/2010.

3. At 3:13 p.m., the Senior Program Manager acknowledged the missing documentation. The facility was given the opportunity to fax and/or email the missing documents on 8/25/17, by 5:00 p.m.

4. On 8/25/17 at 4:49 p.m., eight of twelve monthly visual inspection of the gauges and valves, the annual maintenance, test, and inspection report for the sprinkler system, and report for the five year certification were not received.

Based on document review, the facility failed to provide a written protocol to ensure that if the automatic sprinkler system went out of service for more than 10 hours in a 24-hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by incomplete documentation. This could result in a delay in notification in the event of an emergency with the automatic sprinkler system. This affected the Acute Psych Unit on the second floor.

Findings:

During document review with Senior Program Manager on 8/23/17, the facility's fire watch policy for the automatic sprinkler system was reviewed.

At 2:09 p.m., the documentation provided for an approved fire watch for the automatic sprinkler system did not include guidance for the notification of the California Department of Public Health (CDPH) if the automatic sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, the Senior Program Manager confirmed the finding and stated that they will update their fire watch policy.

Based on document review, the facility failed to maintain their emergency generator. This was evidenced by the failure to provide documentation for 10 of 52 weekly inspections. This could result in a malfunction of the generator and failure to provide backup power to the facility in the event of an emergency. This affected the Acute Psych Unit on the second floor.

NFPA 101, Life Safety Code, 2012 Edition
19.7.6 Maintenance and Testing. See 4.6.12

4.6.12 Maintenance, Inspection, and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems, 2010 edition.
8.3.2.1 The operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Findings:

During document review with the Senior Program Manager on 8/23/17, the generator records were reviewed.

At 1:47 p.m., the facility failed to provide documentation for 10 of 52 weekly inspections for the 175 kilowatt diesel generator. The Senior Program Manager acknowledged the findings.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips and extension cords as a substitute for fixed wiring. This affected the Acute Psych Unit on the second floor, and could result in the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted
in 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 to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

Findings

During a tour of the facility with the Senior Program Manager on 8/23/17, the electrical wiring and equipment was observed.

1. At 11:39 a.m., a fan was plugged into a power strip, in Room 218.

2. At 11:43 a.m., a fan was plugged into an extension cord, in Room 210.

3. At 11:52 a.m., two fans were plugged into a power strip, in Room 236.

4. At 11:56 a.m., a radio was plugged into an extension cord, in Room 231.

Based on observation, the facility failed to maintain their medical gas cylinder storage. This was evidenced by three full oxygen cylinders that were stored freestanding and unsecured. This affected the Acute Psych Unit on the second floor. This could result in increased risk of a damaged to the cylinder and an increased risk of a hazardous condition.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a facility tour with the Senior Program Manager n 8/23/17, the medical gas cylinders were observed.

At 11:48 a.m., there were three full oxygen E-tank that were stored freestanding and unsecured, in Room 237 (Exam Room). The Senior Program Manager acknowledged the finding.