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Based on observation and interview, the facility failed to maintain the interior finish of rooms with a flame spread rating of Class A or Class B.

Finding:

The evaluator conducted an inspection of the facility and observed several rooms with unsealed penetrations: Kitchen - fire sprinkler escutcheon missing exposing the crawl space, Mariah West staff restroom, the Drug Study Room, the basement Medication Record Room, Basement Supervisor and Storage office.

An interview was held with the Building Supervisor and he stated that the unsealed penetrations would be sealed as soon as possible.

Based on observation and interview, the facility failed to ensure that an one hour fire rated construction was provided to hazardous use areas at all times.

Finding:

The evaluator conducted an inspection of the facility and observed that one hour fire rated construction was compromised for the following areas: Mariah East soiled linen room - no self-closing device, Basement Biohazard container located in Tray Room and no self-closing device, 2-East and 2-West - Soiled Linen Room (located near room 236) had no self-closing device and contained a biohazard container.

An interview was held with the Building Supervisor and he stated that the room would have the self-closing device repaired or installed as soon as possible.

Based on interview and record review, the facility failed to ensure that the fire drills were held under varying conditions, at least quarterly, on each shift.

Findings include;

The evaluator conducted a record review of the fire drills which did not contain documented evidence of varied fire emergency situations and conditions.

An interview was held with the person in charge of coordinating the fire drills and he stated that he informs the staff about the different fire emergency situations at the start of the fire drill.

NFPA 72 National Fire Alarm Code 1999 Edition

2-3.4.1.1 The location and spacing of smoke detectors shall result from an evaluation based on the guidelines detailed in this code and on engineering judgement. Some of the conditions that shall be included in the evaluation are the following:

(1) Ceiling shape and surface
(2) Ceiling height
(3) Configuration of contents in the area to be protected
(4) Burning characteristics of the combustible materials present
(5) Ventilation
(6) Ambient Environment

2-3.5.1 In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

The standard was not met as evidenced by:

Based on observation, the facility failed to activate the fire alarm system by automatic detection by having one smoke detector fail to activate the fire alarm system.

Findings Include:

On April 9, 2010, at 10:31 a.m., the evaluator observed the maintenance supervisor test the smoke detector located on the ceiling in the back room of the Las Encinas School. The smoke detector failed to activate the fire alarm system when tested with canned aerosolized smoke.

Closer observation revealed a wall mounted heater/cooler unit was blowing air in the room. After the teacher shut off the heater/cooler unit, the maintenance supervisor again tested the smoke detector with aerosolized smoke spray which activated the fire alarm.

NFPA 72 National Fire Alarm Code 1999 Edition

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101 Life Safety Code 2000 Edition

9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

The standard was not met as evidenced by:

Based on observation, the facility failed to maintain the fire alarm system in accordance with NFPA 72 by obstructing a manual fire alarm box from view.

Findings Include:

On April 9, 2010, at 10:31 a.m., the evaluator, accompanied by the maintenance supervisor, observed drapes located next to the back exit door of Las Encinas School. Closer observation revealed a manual fire alarm was obstructed from view by one of the drapes.

Based on observation and interview, the facility failed to ensure that all the fire sprinklers were maintained in optimal condition at all times.

Finding:

On April 6, 2010, the evaluator conducted an inspection of the Main Building basement and observed that a fire sprinkler was blocked by an air-conditioning duct. On April 7, 2010, at 11:40 a.m., the evaluator observed a missing escutcheon for a fire sprinkler located near the Mariah Adult Unit nurse station.

An interview was held with the Building Engineer and he stated that the concern would be taken care of as soon as possible.

Based on observation and interview, the facility failed to ensure that all smoking areas included the provision for metal containers with self-closing cover devices into which cigarettes could be emptied in all areas where smoking was permitted.

Findings include:

On April 5, 2010, at 2:25 p.m., the evaluator conducted an inspection of the Mariah West Unit. The smoking area is located in back of the unit. The evaluator observed snuffed out cigarettes lying on the ground and walkway. A closer inspection of the approved ashtrays revealed that the bottom of the device was disconnected.

An interview was held with the Building Supervisor and he stated that the area was monitored by staff and he would check the ashtrays as soon as possible.

NFPA 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

NFPA 701 Standard Methods of Fire Tests for Flame Propagation of Textiles and Films 1999 Edition, Chapter 15 Reporting, 15-2.1 The composition and form of the material that was tested shall be described. The description shall include the manner in which the material in the description shall be included.

Based on observation and interview, the facility failed to ensure that the window treatments were in accordance with 10.3.1.

Finding:

The evaluator conducted an inspection of the facility and observed that the windows were covered with curtains and/or draperies. The evaluator checked the curtains and/or draperies for an approved flame resistant tag and/or information. The flame resistant tags were not available for curtains and/or draperies for the following sleeping rooms # 2-south 220, 2-south 221, 2-south 223, 2-south 224, 2-south 225, adjacent to room 231, 232 -south, 233, 235. 236, 237, 244, 2-south 247, 246, 2-south 248, 252, 253, 255, 256, 257, 258, and 259.

An interview was held with the Building Engineer and he stated that there were no documentation regarding the curtain's flame resistance available.

NFPA 10, Standard for Portable Fire Extinguishers 1998, 1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

This requirement is not met as evidenced by:

Based on observation and interview, the facility failed to ensure that all the fire extinguishers were properly secured and installed.

Findings;

The evaluator conducted an inspection of the facility and observed three fire extinguishers not properly secured and anchored.

On April 6, 2010, at 6 2:11 p.m., the evaluator inspected the 2-West Building and observed a portable fire extinguishers held directly on the floor in the Medical Record Room.

An interview was held the Building Engineer and he stated that would secure the portable fire extinguisher as soon as possible.




16281

NFPA 101 Life Safety Code 2000 Edition

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

The standard was not met as evidenced by:

Based on observation, the facility failed to provide a device capable of keeping a corridor door to a vertical opening fully closed.

Finding Includes:

On April 6, 2010, between 10:36 a.m. and 11:35 a.m., the evaluator, accompanied by the maintenance supervisor, observed an interior exit stairway next to room 245 in the 2 South wing of the main building. At the bottom of the stairway, there was a door that opened to a first floor corridor. Closer observation revealed there was no latch at the stairway corridor door.

During an interview the maintenance supervisor stated that a licensed contractor had informed him of the missing latch a few days ago.

Based on observation and interview, the facility failed to maintain the interior finish of rooms with a flame spread rating of Class A or Class B.

Finding:

The evaluator conducted an inspection of the facility and observed several rooms with unsealed penetrations: Kitchen - fire sprinkler escutcheon missing exposing the crawl space, Mariah West staff restroom, the Drug Study Room, the basement Medication Record Room, Basement Supervisor and Storage office.

An interview was held with the Building Supervisor and he stated that the unsealed penetrations would be sealed as soon as possible.

Based on observation and interview, the facility failed to ensure that an one hour fire rated construction was provided to hazardous use areas at all times.

Finding:

The evaluator conducted an inspection of the facility and observed that one hour fire rated construction was compromised for the following areas: Mariah East soiled linen room - no self-closing device, Basement Biohazard container located in Tray Room and no self-closing device, 2-East and 2-West - Soiled Linen Room (located near room 236) had no self-closing device and contained a biohazard container.

An interview was held with the Building Supervisor and he stated that the room would have the self-closing device repaired or installed as soon as possible.

Based on interview and record review, the facility failed to ensure that the fire drills were held under varying conditions, at least quarterly, on each shift.

Findings include;

The evaluator conducted a record review of the fire drills which did not contain documented evidence of varied fire emergency situations and conditions.

An interview was held with the person in charge of coordinating the fire drills and he stated that he informs the staff about the different fire emergency situations at the start of the fire drill.

NFPA 72 National Fire Alarm Code 1999 Edition

2-3.4.1.1 The location and spacing of smoke detectors shall result from an evaluation based on the guidelines detailed in this code and on engineering judgement. Some of the conditions that shall be included in the evaluation are the following:

(1) Ceiling shape and surface
(2) Ceiling height
(3) Configuration of contents in the area to be protected
(4) Burning characteristics of the combustible materials present
(5) Ventilation
(6) Ambient Environment

2-3.5.1 In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

The standard was not met as evidenced by:

Based on observation, the facility failed to activate the fire alarm system by automatic detection by having one smoke detector fail to activate the fire alarm system.

Findings Include:

On April 9, 2010, at 10:31 a.m., the evaluator observed the maintenance supervisor test the smoke detector located on the ceiling in the back room of the Las Encinas School. The smoke detector failed to activate the fire alarm system when tested with canned aerosolized smoke.

Closer observation revealed a wall mounted heater/cooler unit was blowing air in the room. After the teacher shut off the heater/cooler unit, the maintenance supervisor again tested the smoke detector with aerosolized smoke spray which activated the fire alarm.

NFPA 72 National Fire Alarm Code 1999 Edition

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

NFPA 101 Life Safety Code 2000 Edition

9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

The standard was not met as evidenced by:

Based on observation, the facility failed to maintain the fire alarm system in accordance with NFPA 72 by obstructing a manual fire alarm box from view.

Findings Include:

On April 9, 2010, at 10:31 a.m., the evaluator, accompanied by the maintenance supervisor, observed drapes located next to the back exit door of Las Encinas School. Closer observation revealed a manual fire alarm was obstructed from view by one of the drapes.

Based on observation and interview, the facility failed to ensure that all the fire sprinklers were maintained in optimal condition at all times.

Finding:

On April 6, 2010, the evaluator conducted an inspection of the Main Building basement and observed that a fire sprinkler was blocked by an air-conditioning duct. On April 7, 2010, at 11:40 a.m., the evaluator observed a missing escutcheon for a fire sprinkler located near the Mariah Adult Unit nurse station.

An interview was held with the Building Engineer and he stated that the concern would be taken care of as soon as possible.

Based on observation and interview, the facility failed to ensure that all smoking areas included the provision for metal containers with self-closing cover devices into which cigarettes could be emptied in all areas where smoking was permitted.

Findings include:

On April 5, 2010, at 2:25 p.m., the evaluator conducted an inspection of the Mariah West Unit. The smoking area is located in back of the unit. The evaluator observed snuffed out cigarettes lying on the ground and walkway. A closer inspection of the approved ashtrays revealed that the bottom of the device was disconnected.

An interview was held with the Building Supervisor and he stated that the area was monitored by staff and he would check the ashtrays as soon as possible.

NFPA 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

NFPA 701 Standard Methods of Fire Tests for Flame Propagation of Textiles and Films 1999 Edition, Chapter 15 Reporting, 15-2.1 The composition and form of the material that was tested shall be described. The description shall include the manner in which the material in the description shall be included.

Based on observation and interview, the facility failed to ensure that the window treatments were in accordance with 10.3.1.

Finding:

The evaluator conducted an inspection of the facility and observed that the windows were covered with curtains and/or draperies. The evaluator checked the curtains and/or draperies for an approved flame resistant tag and/or information. The flame resistant tags were not available for curtains and/or draperies for the following sleeping rooms # 2-south 220, 2-south 221, 2-south 223, 2-south 224, 2-south 225, adjacent to room 231, 232 -south, 233, 235. 236, 237, 244, 2-south 247, 246, 2-south 248, 252, 253, 255, 256, 257, 258, and 259.

An interview was held with the Building Engineer and he stated that there were no documentation regarding the curtain's flame resistance available.

NFPA 10, Standard for Portable Fire Extinguishers 1998, 1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

This requirement is not met as evidenced by:

Based on observation and interview, the facility failed to ensure that all the fire extinguishers were properly secured and installed.

Findings;

The evaluator conducted an inspection of the facility and observed three fire extinguishers not properly secured and anchored.

On April 6, 2010, at 6 2:11 p.m., the evaluator inspected the 2-West Building and observed a portable fire extinguishers held directly on the floor in the Medical Record Room.

An interview was held the Building Engineer and he stated that would secure the portable fire extinguisher as soon as possible.




16281

NFPA 101 Life Safety Code 2000 Edition

19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

The standard was not met as evidenced by:

Based on observation, the facility failed to provide a device capable of keeping a corridor door to a vertical opening fully closed.

Finding Includes:

On April 6, 2010, between 10:36 a.m. and 11:35 a.m., the evaluator, accompanied by the maintenance supervisor, observed an interior exit stairway next to room 245 in the 2 South wing of the main building. At the bottom of the stairway, there was a door that opened to a first floor corridor. Closer observation revealed there was no latch at the stairway corridor door.

During an interview the maintenance supervisor stated that a licensed contractor had informed him of the missing latch a few days ago.