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The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that in the kitchen dry storage room the clearance between the sprinkler deflector and the top of storage was less than 18 inches.

Interior wall and ceiling finishes in exits and exit access corridors shall have a flame spread rating of Class A or Class B. The reduction in the class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. All other areas may be class C-rated material. Indicate flame spread rating(s) walls.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that the following documentation was not available for review.

Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with NFPA-701

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that the facility did not have the required Type I EES.
The three EES branches per NFPA 99 are:
Life Safety Branch.
Critical Branch.
Equipment Branch.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that the facility did not have the required Type I EES.
The three EES branches per NFPA 99 are:
Life Safety Branch.
Critical Branch.
Equipment Branch.





The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that electrical rooms were being used for storage. This is not allowed.
"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that the following documentation was not available for review.

Records are maintained of required receptacle tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 9:00 am to 12:00 pm on 12/08/22 that
Oxygen Medical Gas bottles were being stored in a small room with an interior access door. This room did not have a medical gas ventilation system. Therefore, the upper limit of medical gas that can be stored in this room is 3000 cubic feet.
? 3,000 cubic feet: Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. (Min. 1 hour enclosure)
> 300 but <3,000 cubic feet: Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
? 300 cubic feet: In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of ? 300 cubic feet are not required to be stored in an enclosure.
Cylinders must be handled with precautions as specified in 11.6.2 A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING". Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)