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Based on document review and interview, the facility failed to maintain the emergency battery backup lighting system. This was evidenced by missing monthly functional testing of the emergency battery backup lighting system. This could result in the increased risk of a complete black out, during a power outage. This affected two of seven buildings.

NFPA 101, Life Safety Code, 2012 Edition.

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.

Findings:

During document review and interview with Staff on 10/23/19, the emergency battery backup lighting system document was requested.

Acute Care Tower and Koret Building:

At 1:50 p.m., the facility failed to provide documentation for the monthly testing of the emergency battery backup lighting system for the months of March, May and July of 2019. When interviewed, A2 and E1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the installation of fire alarm system. This was evidenced by a fire alarm device that was not installed properly. This could lead to a malfunction of the fire alarm system in the event of an emergency, and affected one of seven buildings.

NFPA 101, Life Safety Code, 2012 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 Fire Detection, Alarm, and Communications Systems.
9.6.1.3 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

INSPECTION, TESTING, AND MAINTENANCE, Table 14.3.1

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)


Findings:

During observation and interview with staff on 10/22/19, document was reviewed.

Koret Building:

1. At 2:05, p.m., the smoke detector in Room 3005 was observed. The smoke detector was loosely hanging by a red wire. A zip tie was used to hang the the red wire to a metal bar in the ceiling. Room 3005 was located on K3 floor. There was a tag on the smoke detector that read "TEMP TEST LOCATION 8/23/18".

At 2:10 p.m., when interviewed, the fire alarm technician stated that the smoke detector was probably removed temporary but unsure why the smoke detector has not been moved back to it's original location.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system. This was evidenced by the absence of an annual charger test, an annual 30 minute discharge test, and semi-annual load voltage tests for the back up batteries at the fire alarm control units (FACU). This was also evidenced by the absence of semi-annual fire alarm system inspections and annual fire alarm testing reports that indicated that deficiencies were found and not corrected. This affected three of seven buildings and could result in system impairment during an emergency situation.

NFPA 101, Life Safety Code, 2012 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* General.
9.6.1.5* 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 and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies.
6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Initial/Reacceptance and Annually
(2) Discharge test (30 minutes): Initial/Reacceptance and Annually
(3) Load voltage test: Initial/Reacceptance and Semiannually

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' S published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

10.5.6 Secondary Power Supply.
10.5.6.1* Secondary Power Supply for Protected Premises
Fire Alarm Systems and Emergency Communications Systems.
10.5.6.1.1 The secondary power supply shall consist of one of the following:
(1) A storage battery dedicated to the system arranged in accordance with 10.5.9
(2) An automatic-starting, engine-driven generator serving the dedicated branch circuit specified in 10.5.5.1 and arranged in accordance with 10.5.10.3.1, and storage batteries dedicated to the system with 4 hours of capacity arranged in accordance with 10.5.9


Findings:

During document review, observation, and interview with Staff, the fire alarm system was observed and records were requested.

San Leandro Campus

The Main FACU was located in the Electrical Room 2B on Floor 2. The FACU was equipped with six sealed lead-acid back-up batteries that were installed on 9/19/19.

1. On 10/23/19, at 10:31 a.m., there were no records provided that indicated that the six batteries had a load voltage test, a charger test, or a 30 minutes discharge test when they were initially installed on 9/19/19. Upon interview, E3 and A4 confirmed this finding and stated that they verified with the fire alarm vendor that the test were not completed.

Fairmont Campus-Building H

2. On 10/24/19, at 8:48 a.m., there were no records that indicated that a semi-annual fire alarm system inspection was completed. Upon interview, Engineer Manager E2 confirmed this finding and stated that they were not aware of this requirement, but would schedule a semi-annual inspection with their fire alarm system vendor.

3. On 10/24/19, at 11:10 a.m., a document titled "Inspection and Testing Form" dated 8/20/19 was provided. The document indicated the annual fire alarm system inspection and testing was completed. Page 5 of 6 stated the following: "Batteries failed load testing and need replacement." There was no documentation provided that indicated that the batteries were replaced. Upon interview, Engineer Manager E2, Vice President of Support Services A8, and Facilities Manager A1 confirmed this finding and stated that the batteries had been replaced.

During a tour of the facility, the FACU located in FACU Room 132 on Floor 1 was observed. The FACU was equipped with two sealed lead acid batteries. One battery was dated 8/1/12 and the other was dated 4/28/16. Upon interview, Engineer Manager E2, and Facilities Manager A1 confirmed this finding and they stated that they had been under the impression that the batteries had been replaced.


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John George Psychiatric:

4. On 10/23/19 at 9:45 a.m., the annual inspection and testing report provided dated 10/7/19 indicated that "All smoke detectors in B unit did not report to panel". When interviewed, A1 stated that the issue with the smoke detectors in B unit will be resolved when they replace the fire alarm system.

5. On 10/24/19 at 10:53 a.m., staff A3 stated that the smoke detectors are part of the Office of Statewide Health Planning and Development (OSHPD) project. An emergency replacement of the fire alarm system was approved by OSHPD on 10/8/19. The OSHPD project number is S192503-01-00.

6. On 10/23/19, at 1:17 p.m., the facility failed to provide documentation for the semi-annual fire alarm system inspection at time of survey. When interviewed, A3 confirmed the finding.

7. On 10/23/19, at 1:18 p.m., the facility failed to provide the semi-annual load voltage test for the sealed lead-acid batteries at time of survey. When interviewed, A3 confirmed the finding.

Based on document review and interview, the facility failed to maintain the fire alarm system out of service policy. This was evidenced by the absence of requiring the notification of the system disruption to the authority having jurisdiction (AHJ). This affected two of seven buildings and could result in delayed emergency assistance in the event of a fire during fire alarm system disruption.

Findings:

During document review and interview with Staff on 10/23/19, the fire alarm system out of service policy was requested.

San Leandro Campus

1. On 10/23/19, at 10:14 a.m., the firewatch policy did not state that the AHJ must be contacted if the fire alarm system is impaired for more than four hours in a 24-hour period. Upon interview, A4 confirmed this finding.

Fairmont Campus-Building H

2. On 10/23/19, at 3:20 p.m., the firewatch policy did not state that the AHJ must be contacted if the fire alarm system is impaired for more than four hours in a 24-hour period. Upon interview, A1 confirmed this finding and stated that they would add the notification to AHJ to the policy.

Based on document review and interview, the facility failed to maintain their smoke alarms. This was evidenced by no documented evidence that the smoke alarms were tested for sensitivity. This could result in delayed notification of fire to the building occupants and cause injury from smoke inhalation and burns. This affected five of seven buildings.

NFPA 101, Life Safety Code, 2012 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 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.2 Purpose. The purpose of the fire alarm and signaling systems shall be primarily to provide notification of alarm, supervisory, and trouble conditions; to alert the occupants; to summon aid; and to control emergency control functions.

10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.

14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.

14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During document review with staff, the documents for the smoke alarm sensitivity were requested.

Acute Care Tower, Highland Care Pavilion and Koret Building

1. On 10/23/19, at 1:30 p.m., the facility failed to provide documentation for the sensitivity testing of the smoke alarms. At 1:33 p.m., E1 was interviewed. He stated that he was not aware that a sensitivity test was required for the smoke alarms.



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John George Psychiatric:

2. On 10/23/19, at 1:20 p.m., the facility failed to provide a smoke detector sensitivity test report upon request. When interviewed, A1 confirmed the finding and stated that it has not been done for John George Psychiatric.


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Fairmont Campus Building H:

3. On 10/24/19, at 8:45 a.m., there were no records provided that indicated that 10 of 10 system smoke detectors had been tested for smoke sensitivity. Upon interview, the E2 confirmed this finding and stated that they need to schedule a smoke sensitivity test.

Based on observation, document review and interview, the facility failed to maintain the automatic sprinkler systems. This was evidenced by the failure to correct deficiencies noted on the sprinkler system inspection/test/maintenance reports, by missing one of four quarterly inspections, by the failure to provide an annual maintenance, testing, and inspection for the sprinkler system and by the failure to complete twelve monthly inspections on sprinkler gauges and control valves. This could result in a malfunction of the automatic sprinkler system and a potential delay in extinguishing a fire resulting in injury to residents in the event of a fire. This affected five of seven buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment
9.7.1 Automatic Sprinklers.

9.7.4.2 Where required by the provisions of another section of this Code, standpipe and hose systems shall be provided in accordance with NFPA 14, Standard for the Installation of Standpipe and Hose Systems. Where standpipe and hose systems are installed in combination with automatic sprinkler systems, installation shall be in accordance with the appropriate provisions established by NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 14, Standard for the Installation of Standpipe and Hose Systems.

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.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

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 13, Standard for the Installation of Sprinkler Systems, 2010 Edition
6.7.4* Identification of Valves.
6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs.
6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means.
6.7.4.3 The control valve sign shall identify the portion of the building served.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
4.1.4* Corrections and Repairs.
4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.
4.1.4.2* Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

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.
5.2.2* 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.

5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible.

5.3 Testing.
5.3.1* Sprinklers.
5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.
5.3.1.1.1.1 Test procedures shall be repeated at 10-year intervals.
5.3.1.1.1.2 Sprinklers manufactured prior to 1920 shall be replaced.
5.3.1.1.1.3* Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.

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.

Findings:

During a tour of the facility, document review and interview with Staff, the automatic sprinkler system was observed, and documents were reviewed.

Acute Care Tower:

1. On 10/23/19, at 11:10 a.m., the facility failed to provide an annual and third (July/August/September 2019) quarter maintenance, test, and inspection report for the sprinkler system upon request. The last annual/third quarter inspection was conducted on 8/24/18.

2. On 10/23/19, at 11:13 a.m., the documents provided by the facility for the quarterly inspections for the first, second and fourth quarters, dated 3/20/19, 6/25/19 and 12/10/18 indicated "FAILED." The deficiencies were all the same and indicated the following under Deficiencies and Comments: 1.19: 7FL staff Restroom Next To Conference Room 7441 Painted HT1 @8' HC. P.106/106; 1.19: 9FL Patient Room 9909 inside the Restroom painted HT1 @ 8' HC.; 1.19: 9FL Patient Room 9919 inside the Restroom painted HT1 @ 8' HCl; 9FL Patient Room 9921 inside the Restroom painted HT1 @ 8' HC. ** PLEASE NOTE ** All deficiencies were identified during the annual inspection (2018) and were found to still be existing.

At 11:15 a.m., the E1 and A2 were interviewed. The E1 confirmed the findings and A1 stated that they are currently transitioning to a new vendor.

3. On 10/23/19, at 11:17 a.m., the documents provided for the wet pipe sprinkler system failed to include monthly gauges and control valves inspections for January, February, April, May, July, August, and September of 2019; October and November of 2018. When interviewed, E1 stated that the monthly visual inspections of components to the wet pipe sprinkler system were conducted during the sprinkler quarterly tests which was conducted on March and June of 2019; and December 2018.


Highland Care Pavilion:
4. On 10/23/19, at 11:39 a.m., the documentation provided for the five-year certification inspection conducted on 9/3/19 was marked Failed with the following comments: P1 and P0 - 7 arm piping to sprinklers not properly supported (not to exceed 1'-0" hanger to sprinkler).

5. On 10/23/19, at 11:50 a.m., the documents provided for the wet pipe sprinkler system failed to include monthly gauges and control valves inspections for January, February, April, May, July, August, and September of 2019; October and November of 2018. When interviewed, E1 stated that the monthly visual inspections of components to the wet pipe sprinkler system were conducted during the sprinkler quarterly tests which was conducted on March and June of 2019; and December 2018.

6. On 10/23/19, at 1:17 p.m., the facility failed to provide an annual and third (July/August/September 2019) quarterly maintenance, test, and inspection report for the sprinkler system upon request. The last annual/third quarterly inspection was conducted on 8/21/18.

Koret Building:
7. On 10/23/19, at 1:18 p.m., the facility failed to provide an annual and third (July/August/September 2019) quarter maintenance, test, and inspection report for the sprinkler system upon request. The last annual/third quarter inspection was conducted on 8/22/18.

8. On 10/23/19, at 1:20 p.m., the documents provided for the wet pipe sprinkler system failed to include monthly gauges and control valves inspections for January, February, April, May, July, August, and September of 2019; October and November of 2018. When interviewed, E1 stated that the monthly visual inspections of components to the wet pipe sprinkler system were conducted during the sprinkler quarterly tests which was conducted on March and June of 2019; and December 2018.


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Acute Care Tower:
9. On 10/22/19 at 11:27 a.m., the sprinkler in the office was observed with debris build up around the deflector. The office was in the Kitchen located on the second floor. When interviewed, A1 confirmed the finding.

10. On 10/22/19 at 2:40 p.m., the sprinkler between Room 2 and eye wash station had debris build up around the deflector. When interviewed, A1 and A2 confirmed the finding.


John George Psychiatric:
11. On 10/23/19, at 1:40 p.m., there were no records provided for the monthly inspections of the sprinkler gauges and valves at time of survey. The facility conducts quarterly inspections and were conducted on 2/5/19, 6/24/19, 8/28/19, and 10/17/19. The facility did not provide monthly inspections for the months of January, March, April, May, July, September of 2019, and November, December of 2018. When interviewed, A3 confirmed the finding.



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Fairmont Campus-Building H:

12. On 10/24/19, at 9:33 a.m., a document titled "Inspection, Testing, and Maintenance" dated 8/28/19 was provided. The document indicated the sprinkler system had failed due to a deficiency found during the annual sprinkler system inspection/test completed on 11/29/18. Page 2 of 3 of the document indicated that the Floor 2 Men's Restroom across from beds 21-26 had a 50 year old sprinkler head. Upon interview, E2 and A8 confirmed this finding and provided an invoice dated 6/20/19. The invoice indicated that the 50 year old sprinkler heads in the Rehabilitation area had been replaced and that the sprinkler head on the second floor could not be replaced.

13. On 10/24/19, at 9:38 a.m., records indicated that monthly visual inspections for the alarm and system riser check valves and pressure gauge for the following months were not completed: December of 2018, and January, March, April, May, July, and September of 2019. Upon interview, E2 confirmed this finding and stated they were not aware of this requirement.

14. On 10/24/19, at 10:37 a.m., the sprinkler heads in the Fire Alarm Control Unit Room 132 were observed. The sprinkler head located near the entry door was missing an escutcheon plate creating a penetration that was approximately 2 1/2 inch diameter in size. Upon interview, E2 and A1 confirmed this finding.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system out of service policy. This was evidenced by the absence of requiring the notification of the system disruption to the authority having jurisdiction (AHJ). This affected two of seven buildings and could result in delayed emergency assistance in the event of a fire during sprinkler system disruption.

Findings:

During document review and interview with staff on 10/23/19, the sprinkler system out of service policies was requested.

San Leandro Campus

1. At 10:14 a.m., the firewatch policy did not state that the AHJ must be contacted if the automatic sprinkler system is impaired for more than 10 hours in a 24-hour period. Upon interview, A4 confirmed this finding.

Fairmont Campus-Building H

2. At 3:20 p.m., the firewatch policy did not state that the AHJ must be contacted if the automatic sprinkler system is impaired for more than 10 hours in a 24-hour period. Upon interview, A1 confirmed this finding and stated that they would add the notification to AHJ to the policy.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by one extinguisher that was freestanding on the floor and not secure. This affected one of seven buildings and could result in the damage of the extinguisher and malfunction in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Extinguishers, 2010 Edition.
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

Findings:

During a tour of the facility and interview with Staff on 10/23/19, the portable fire extinguishers were observed.

San Leandro Campus:

At 1:47 p.m., Generation 1 Room was observed. There was an ABC type portable extinguisher sitting on the floor near the entry door. The extinguisher was freestanding and not secure. Upon interview, A4 confirmed this finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by four corridor doors that were obstructed from closing and another three that did not latch when tested. This affected two of seven buildings and could result in the spread of fire and/or smoke in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.10* Doors shall not be held open be devices other then those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with Staff, the corridor doors were observed.

San Leandro Campus

1. On 10/23/19, at 1:11 p.m., the corridor door to Patient Room 215 in the Med-Surg Unit located on Floor 2 was observed. The door was obstructed from closing by a 32 gallon dirty linen hamper that was placed directly in front of the door.

2. On 10/23/19, at 1:12 p.m., the corridor door to Patient Room 214 in the Med-Surg Unit located on Floor 2 was observed. The door was obstructed from closing by a 32 gallon dirty linen hamper that was placed directly in front of the door.

3. On 10/23/19, at 1:35 p.m., the corridor door to the Janitor Closet Room 326 in the Outpatient Operating Room Unit located on Floor 1 did not latch when tested. The door was equipped with a self-closing device.

4. On 10/23/19, at 1:36 p.m., the corridor door to the Surgical Sterile Storage Room 324 in the Outpatient Operating Room Unit located on Floor 1 did not latch when tested. The door was equipped with a self-closing device.

The findings were acknowledged by A4.




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Acute Care Tower:

5. On 10/21/19, at 2:15 p.m., the corridor door to Room 9418 was equipped with a self-closing device. The door could not fully close due to a housekeeping cart that obstructed the door. When interviewed, A1 confirmed the finding.



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Acute Care Tower:
6. On 10/22/19, at 10:42 a.m., the double door to the Electrical Room 6408 on the sixth floor was observed. The double door was equipped with a self-closing device. The left door failed to latch when fully opened and released. When interviewed, A2 confirmed the finding.

7. On 10/22/19, at 10:48 a.m., the double door to the Storage Room 6701 on the sixth floor was observed. The double door was equipped with a self-closing device. The right door failed to latch when fully opened and released. When interviewed, A2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the smoke integrity of the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire. This affected two of seven buildings.

NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Findings:

During a tour of the facility and interview with Staff, the smoke barrier walls were observed.

Acute Care Tower:
1. On 10/21/19 at 2 p.m., there was an approximately 1 ½-inch unsealed penetration around a metal conduit in the smoke barrier wall. The smoke barrier wall was located near the Staff Lounge on the eighth floor. When interviewed, M1 confirmed the finding.

Koret Building:
2. On 10/22/19, at 9:30 a.m., there was an approximately ¼- inch unsealed penetration between two metal conduits in the smoke barrier wall. The smoke barrier wall was near the staff entrance to the operating rooms on the K5 floor. When interviewed, M2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the smoke barrier doors. This was evidenced by a smoke barrier door that was held open by a rubber wedge. This affected one of seven buildings and could result in the inability to contain smoke and/or fire.

Findings:

During a tour of the facility and interview with staff on 10/23/19, the smoke barrier door was observed.

John George Psychiatric :

1. At 11:04 a.m., the 45-minute fire rated smoke barrier door in Unit C was observed. The left leaf was held open by a rubber wedge. When interviewed, A1 stated he was unsure why the left leaf was not holding and that he will find out if there was a work order that was submitted.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by electrical panels that were obstructed from access and by a receptacle outlet that was not maintained. This affected three of seven buildings and could result in delay of access in the event of an emergency.


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

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels

314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.


Findings:

During a tour of the facility and interview with staff, the electrical equipment were observed.

Koret Building:

1. On 10/22/19, at 2:21 p.m., the access to the electrical panel "Emergency Power Panel" in Room K322 was obstructed by a computer cart. The computer cart was placed directly in front of the access door. Room K322 was located on K3 floor. A1 moved the cart to gain access to the panel.


E Wing Building:

2. On 10/22/19, at 2:35 p.m., the receptacle outlet faceplate in the Dental Registration area was observed. The faceplate for the receptacle outlet was missing. The Dental Registration area was located on the first floor in E wing.



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San Leandro Campus:

3. On 10/23/19, at 11:30 a.m., the electrical panels in Electrical Room 2S located on Floor 2 were observed. Panel EL2B, Panel L2B, and Panel NDLB were obstructed from accessing by two 32 gallon receptacles and three emergency lighting equipment storage boxes that were stationed directly in front of the panels. This finding was acknowledge by A4 and E3 who moved the items to a different location.

Based on document review and interview, the facility failed to maintain fire drills. This was evidenced by the failure to provide fire drill records for all shifts once per quarter. This could result in staff to ineffectively protect patients in the event of an actual fire and could result in injury. This affected three of seven buildings.

Findings:

During document review and interview with the Hospital Staff on 10/23/19, the fire drill records were reviewed.

Acute Care Tower:
1. At 10:22 a.m., the facility failed to provide documentation for two of 12 fire drills at least quarterly on each shift. The facility failed to provide the PM shift fire drill during the first quarter (January/February/March 2019) and the second quarter (April/May/June 2019). When interviewed, E1 and A2 confirmed the finding.

Koret Building:
2. At 10:23 a.m., the facility failed to provide documentation for one of 12 fire drills at least quarterly on each shift. The facility failed to provide the AM shift fire drill during the second quarter (April/May/June 2019). When interviewed, E1 and A2 confirmed the finding.

Highland Care Pavilion:
3. At 10:24 a.m., the facility failed to provide documentation for nine of 12 fire drills at least quarterly on each shift. The facility failed to provide the AM shift fire drill during the first quarter (January/February/March 2019); PM shift fire drill during the first, second, third, and fourth quarter (April/May/June 2019); and the NOC shift fire drill during the first, second, third, and fourth quarter (October/November/December 2018). When interviewed, E1 and A2 confirmed the finding.

Based on document review and interview, the facility failed to maintain the door openings. This was evidenced by an annual inspection and test for fire door assemblies that indicated deficiencies were found and not corrected. This affected one of seven buildings and could result in the malfunction of the egress doors during an emergency situation.

NFPA 101. Life Safety Code, 2012 Edition
19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.)

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition
5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.3 Functional Testing.
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.
5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.
5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Findings:

During document review and interview with Staff on 10/24/19, the annual inspection and testing reports for fire doors were requested.

Fairmont Campus-Building H

1. At 8:51 a.m., a document titled "Fire Door Inspection Sheet" dated 10/14/19 was provided. The document indicated that the Occupational Therapy Manager Door-NCI 1058 and the Men's Dressing Room Door-NCI 1059 failed inspection both due to "holes in the door." Upon interview, E2 confirmed this finding and stated that they were in the process of scheduling repairs for the two doors.

Based on document review and interview, the facility failed to maintain the gas and vacuum piped system. This was evidenced by the failure to address noted deficiency during the annual certification. This affected one of seven buildings and could result in malfunction of the system.

Findings:

During document review and interview with Staff on 10/24/19, the document was reviewed.

Koret Building:

1. At 10:50 a.m., the medical gas annual report dated September 2019 was reviewed. During the annual calibrations, it was noted that 8 PC boards failed and needed to be replaced. When interviewed, E1 stated that the vendor will replace PC boards approximately by 11/1/19.

Based on observation and interview, the facility failed to maintain the electrical systems. This was evidenced by the failure to provide listed tamper-resistant or safety outlet cover to the receptacle outlets in pediatric locations. This affected one of seven buildings and could result in the risk of electrical injuries.

Findings:

During a tour of the facility and interview with Staff on 10/22/19, the receptacle outlet was observed.

Koret Building-Pediatric Department:

1. At 1:45 p.m., the receptacle outlets in Exam Room 2 (Room K644) were not equipped with listed tamper-resistant or safety outlet cover. The exam room was located on K6 floor. This finding was confirmed by A1 and stated that the receptacle outlets are not tamper resistant.

2. At 1:48 p.m., the receptacle outlets in Exam Room 7 (Room K641) were not equipped with listed tamper-resistant or safety outlet cover. The exam room was located on K6 floor. This finding was confirmed by A1.

3. At 1:50 p.m., the receptacle outlets in Triage room (Room K647) were not equipped with listed tamper-resistant or safety outlet cover. The exam room was located on K6 floor. This finding was confirmed by A1.

Based on observation, document review, and interview, the facility failed to maintain the electrical system and its components. This was evidenced by the failure to provide the electrical receptacle testing records. This affected one of ten floors in the Buchanan Building and one of seven floors in the California Building, and could result in an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition
Chapter 6 Electrical Systems

6.3.2.2.8.1* Wet procedure locations shall be provided with special protection against electric shock.

6.3.2.2.8.5 In existing construction, the requirements of 6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital to indicate that equipment grounding conductors for 120-V, single-phase, 15-A and 20-A receptacles; equipment connected by cord and plug; and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and the applicable performance requirements of this chapter.

(B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months

6.3.2.6.3 Line Isolation Monitor.

6.3.2.6.3.1* In addition to the usual control and protective devices, each isolated power system shall be provided with an approved, continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated
conductor to ground.

6.3.2.6.3.2 The monitor shall be designed such that a green signal lamp, conspicuously visible in the area where the line isolation monitor is utilized, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA.

6.3.2.6.3.4* An ammeter connected to indicate the total hazard current of the system (contribution of the fault hazard current plus monitor hazard current) shall be mounted in a plainly visible place on the line isolation monitor with the "alarm on" zone (total hazard current = 5.0 mA) at approximately the center of the scale. A line isolation monitor shall be located in the operating room.

6.3.2.6.3.5 Means shall be provided for shutting off the audible alarm while leaving the red warning lamp activated. When the fault is corrected and the green signal lamp is reactivated, the audible alarm-silencing circuit shall reset automatically, or an audible or distinctive visual signal shall indicate that the audible alarm is silenced.

6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

Findings:

During a tour of the facility, document review, and interview with Staff, the records were requested.

Acute Care Tower/Highland Care Pavilion/Koret Building:

1. On 10/24/19, at 10:29 a.m., the facility failed to provide records for the annual electrical receptacle testing at time of survey. There were no previous records provided to indicate when the receptacles were last tested. When interviewed, E1 confirmed the finding.




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Koret Building:

2. On 10/23/19, at 9:25 a.m., the Line isolation monitor (LIM) in Operating Room 6 located on K5 floor was observed. The LIM was not visible and was obstructed by an electrical surgical unit. The electrical surgical unit was placed directly in front of the LIM. A1 moved the electrical surgical unit to observe the monitor.

Based on document review and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by the failure to provide complete records of the weekly visual inspections, the failure to conduct a fuel quality test at least annually, and by the failure to record the transfer time during the monthly load tests. This could result in the ineffective operation of the generator in the event of an emergency. This affected three of seven buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
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

8.3.4.1 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

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

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.

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.
8.4.2.4.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.4.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.3 The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required.
8.4.4 Load tests of generator sets shall include complete cold starts.
8.4.5 Time delays shall be set as follows:
(1) Time delay on start:
(a) 1 second minimum
(b) 0.5 second minimum for gas turbine units
(2) Time delay on transfer to emergency: no minimum required
(3) Time delay on restoration to normal: 5 minutes minimum
(4) Time delay on shutdown: 5 minutes minimum
8.4.6 Transfer switches shall be operated monthly.
8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

NFPA 99, Health Care Facilities Code, 2012 Edition
6.4.4.1.1.1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.10 and 6.4.3.1.

6.4.4.1.1.2 The 10-second criterion shall not apply during the monthly testing of an essential electrical system. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm the capability of the life safety and critical branches to comply with 6.4.3.1.

6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Findings:

During document review and interview with the Staff, the generator maintenance document was requested, and staff interviewed.

Acute Care Tower/Highland Care Pavilion/Koret Building:
1. On 10/23/19, at 10:46 a.m., the facility failed to provide documentation for the annual fuel quality test of Generator 1 - 2000 Kw, Generator 2 - 2000 kw and 450 Kw diesel fuel powered generators upon request. The last annual fuel quality test was conducted on 9/6/18. When interviewed, the A1 the confirmed the finding.

2. On 10/23/19, at 10:51 a.m., the facility did not provide records for 20 of 52 weekly visual inspections for their three generators at the time of survey. When interviewed, the A1 confirmed the finding.

3. On 10/23/19, at 11:08 a.m., the monthly load tests failed to include the transfer time for the past 12 months. The finding was confirmed the A1 and E1.



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John George Psychiatric:

4. On 10/23/19 at 1:30 p.m., the facility failed to provide document for the monthly conductance test of the battery in the generator. The 200 kW diesel powered generator was equipped with maintenance free battery. When interviewed, E2 stated that there is no monthly testing of the battery because the battery is maintenance free. E2 further stated that the battery was replaced 2/21/18.




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Fairmont Campus - Building H:

5. On 10/24/19 during a tour of the facility, two generators were observed located outside near the Engineer Building. Both generators were equipped with two maintenance free sealed lead acid batteries. Upon interview, E2 and A1 confirmed this observation and stated that both generators powered Building H.

6. At 9:44 a.m., there were no records provided that indicated that the four sealed lead-acid batteries on the generators were being tested for conductance on a monthly basis. Upon interview, E2 confirmed this finding and stated they were not aware of this requirement and would start testing the batteries monthly.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by the improper use of power strips. This affected one of seven buildings. This could potentially result electrical shock or 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 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.


Findings:

During a tour of the facility and interview with staff on 10/21/19, the electrical equipment and wiring were observed.

Acute Care Tower:

1. At 1:55 p.m., there was a power strip plugged into another power strip in Room 9103. The power strips were used to power phone charger, printer, and electric stapler. Room 9103 was adjacent to the chapel on the ninth floor. When interviewed, A1 and A2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain their patient care related electrical equipment. This was evidenced by the failure to provide maintenance and testing documentation for the relocatable power tap attached to a portable cart in the operating room. This could result in electrical equipment malfunction. This affected one of seven buildings.

Findings:

During a tour of the facility, document review, and interview with staff on 10/23/19, the document was requested and relocatable power tap observed.

Koret Building:

1. At 9:27 a.m., relocatable power tap attached to a portable cart was observed in Operating Room 6. There were no maintenance and testing records provided for the attached power strip at time of survey. When interviewed, the A2 stated that per Bio-Med staff, there was no testing of the relocatable power tap in the operating room or a maintenance and testing policy.

Based on observation and interview, the facility failed to maintain the oxygen cylinder storage. This was evidence by an Oxygen Storage Room that had combustibles stored next to oxygen E-tanks and did not have a precautionary sign. This was also evidenced by two oxygen E-tanks that were stationed in a location where they could be damaged. This affected two of seven buildings and could result in fire ignition.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1.2 hour

11.3.4.1 A precautionary sign, readable from a distance of
1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a
minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3.

11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3.
11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder,
valve, or safety device.

Findings:

During a tour of the facility and interview with staff from 10/21/19 through 10/25/19, the Oxygen Cylinder Storage Rooms were observed.

San Leandro Campus

1. On 10/24/19, at 1:17 p.m., the Oxygen Storage Room in the Med-Surg Unit located on Floor 2 was observed. There were two oxygen E-tanks, each sitting in a single tank cart that were stationed directly in front of the Nurse Call System Panel. The floor area in front of the panel was taped off. The oxygen E-tanks were stationed within the area. When the door to the panel could not be fully opened without moving the E-tanks. Upon interview, A4 and A10 confirmed this finding and stated that the E-tanks should not have been stored at the location.



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Acute Care Tower:

2. On 10/22/19, at 10:45 a.m., the Oxygen Storage Room (Room 5222) located on the fifth floor was observed with combustible materials stored less than 5 feet from the cylinders. The room contained 4 empty E-cylinders, 12 full E-cylinders, 2 full nitrogen cylinders, 2 full medical air gas cylinders, 2 full helium cylinders, and 4 full 3L oxygen cylinders.

The Oxygen Storage Room door was also observed without a precautionary sign on the door. When interviewed, A1 confirmed the findings.