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Based upon observation, exit access from rooms are arranged to require egress thru adjacent smoke compartments. Failure to provide at least one exit access door and exit without requiring egress thru an adjacent smoke compartment can endanger occupants when forced to enter the adjacent compartment if that compartment is the compartment of fire/smoke origin.

Findings include:

On March 10, 2020 at 2:55pm while in the company of the DPO, it was observed that the 3rd floor Adult Day room and adjacent Laundry room require egress thru the adjacent smoke compartment to reach an exit because the only egress doors from these rooms are in the designated smoke barrier corridor wall which does not comply with 19.2.4.4.

Based upon observation, identification of required exit access is not provided to comply with Code requirements. Failure to adequately identify exit access can result in confusion or inability of occupants to gain access to an exit during a fire/smoke condition.

Findings include:

On March 10, 2020 at 2:20pm while in the company of the DPO, it was observed that the 3665 sf New Choice suite lacked adequate identification of the 2nd required exit access door from the suite to comply with 19.2.5.5.2 because the 2nd exit requires movement thru an intervening room and the door to this room is not provided with an exit sign to comply with 7.10.1.2.1.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On March 10, 2020 at 2:30pm while in the company of the DPO, it was observed that exit discharge lighting could not be conmfirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all exit discharge locations were provided with multiple fixtures (or confirmed to be fixtures with multiple lamps) to comply with 7.8.1.4. Locations observed included the south facade exit doors and the west facade exit door.

Based upon observation, cooking facilities are not maintained in accordance with Code requirements. Failure to maintain cooking facilities can result in a fire or smoke condition which can compromise the safety of building occupants.

Findings include:

A. On March 10, 2020 at 11:00am while in the company of the DPO, during record document review of the Kitchen hood & fire suppression system, it appeared that testing of the gas solenoid valve (for gas appliances) and electric shunt trip (for electric appliances) under the hood were not tested as part of the inspection & testing visits to comply with NFPA 96-2011, 10.4.1. The 4/17/19 & 10/8/19 inspection reports appeared to be marked "N/A".

B. On March 10, 2020 at 2:00pm while in the company of the DPO, it was observed that the Kitchen hood grease filters were not installed to prevent exhaust air from by-passing the filters as required by NFPA 96-2011, 6.2.3.3. The filters were not tight-fitting without gaps between the filters.

Based upon document review and staff interview, sprinkler system components are not documented to be tested and maintained in accordance with Code requirements. Failure to test and maintain the sprinkler system components can result in failure of the system to provide effective fire suppression of a fire event which can affect the safety of building occupants.

Findings include:

On March 10, 2020 at 10:15am while in the company of the DPO during record document review, it was noted that the annual fire pump testing documentation available (dated 6/13/19) indicated that the fire pump was not tested while on emergency power. This does not comply with NFPA 25-2011, 8.3.3.4.

Based upon document review and staff interview, the emergency generator system is not maintained in accordance with Code requirements. Failure to maintain the emergency generator can result in loss of electrical power for the facility during public utility power loss.

Findings include:

On March 10, 2020 at 10:30am while in the company of the DPO, it was indicated by record document review and discussion with the DPO that the emergency generator starting battery electrolyte specific gravity for each cell of the batteries is not being checked or recorded at least monthly as required by NFPA 110-2010, 8.3.7.1. A single entry of "good" is entered on the weekly record forms which adequate for checking the level of electrolyte to comply with NFPA 110-2010, 8.3.7. The forms do not provide for an entry for each cell of the batteries to tabulate the specific gravity condition. The DPO indicated that not every cell was checked when testing is performed.