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Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in walls. This could result in the passage of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments.

Findings:

During a tour of the facility with the Director of Support Services, on June 19 and June 20, 2012, the walls and ceilings were observed.

Unit 1
1. At 2:40 p.m., there was an approximately 4 inch penetration, on the right wall, in the clean linen room.
2. At 2:43 p.m., there was an approximately 1 inch penetration in the staff breakroom, behind the door, by the time clock.
3. At 2:45 p.m., in the medication room, there were 11 approximately 1/8 inch to 1/4 inch penetrations, on the back wall.
4. At 2:47 p.m., there were 2 approximately 1/4 inch penetrations, in Room 102, above the sink.

Unit 2-B
5. At 3:18 p.m., there were 2 approximately 3/4 inch penetrations on the left wall, in the storage room.

Unit 3
6. At 3:39 p.m., there were 5 approximately 1/4 inch to 1/2 inch penetrations on the back wall in the Lab Storage area.
7. At 3:40 p.m., in the medication room the corridor wall had an approximately 1/4 inch penetration.
8. At 3:43 p.m., there was an approximately 2 inch penetration on the back wall in the seclusion bathroom.
9. At 4:03 p.m., there were three approximately 3/4 inch penetrations and three approximately 1/8 inch penetrations on the right wall of the maintenance office.

Based on observation, the facility failed to maintain the corridor walls to resist the passage of smoke in the event of a fire. This was evidenced by penetrations in corridor walls. This affected 2 of 6 smoke compartments and could result in the passage of smoke and flames.

Findings:

On June 19, and June 20, 2012, during a tour of the facility with the Director of Support Services, the corridor walls were observed.

June 20, 2012
1. At 9:50 a.m., the corridor wall outside the cafeteria had an approximately 3 foot by 3 foot cut out in the 1 hour wall.
2. At 9:55 a.m., the corridor wall by the assessment office had an approximately 3 inch pipe unsealed at each end.

Based on observation, the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that were obstructed from closing and doors that failed to latch. This affected 3 of 6 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Support Services, the doors were observed.

June 19, 2012
1. At 2:26 p.m., the door to Consult Room B was obstructed from closing by a chair placed in front of the door.
2. At 2:38 p.m., the door to Consult Room C was obstructed from closing by a chair placed in front of the door.

Unit 3
3. At 3:40 p.m., the medication room door was held open with a wedge.
4. At 4:07 p.m., in the kitchen, the locker room door failed to latch after closing.

Based on observation, the facility failed to maintain the smoke barrier walls in 5 of 6 smoke compartments. This could result in the passage of smoke and flames from one smoke compartment to another in the event of a fire.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Support Services, the smoke barrier walls were observed.

June 20, 2012
1. At 9:46 a.m., there was an approximately 6 inch pipe around communication wires in the smoke barrier wall by AT. The pipe was not sealed on either side of the smoke barrier.

2. At 9:48 a.m., there was an approximately 4 inch penetration in the smoke barrier by the cafeteria.

3. At 9:55 a.m., there was an approximately 5 inch pipe sleeve in the smoke barrier wall by the assessment area. The pipe sleeve was not sealed.

4. At 9:58 a.m., the smoke barrier by the gym had an approximately 1 inch penetration along the left side of a pipe in the center of the wall.

Unit 3
5. At 10:37 a.m., there was an approximately 2 inch penetration in the smoke barrier wall by Room 222.

Based on observation and interview, the facility failed to maintain the battery operated emergency lights on 3 of 5 patios. This was evidenced by no records for monthly and annual testing for the emergency lights. This could result in a delay of evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Staff Services, the emergency lights were observed.

June 19, 2012 - Unit 1
1. At 2:55 p.m., on the patio there were two emergency battery operated lights. During an interview, the Director of Support Services stated he does not test the lights. The lights were installed by a vendor, when they did an expansion, because the vendor had equipment and supplies on the patios.

Unit 2 B
2. At 3:12 p.m., the patio had two emergency battery operated lights. The Director of Support Services reported there was no documentation for testing the lights monthly or annually. The lights were not tested.

Unit 2 A
3. At 3:25 p.m., the patio had three emergency battery operated lights. There was no documentation for testing the lights monthly or annually.

During the survey the lights could not be tested. There was a protective cover that was placed over the lights.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. This was evidenced by one sprinkler that was coated with dust and lint. This affected 1 of 6 smoke compartments and could result in the failure of the sprinkler pattern to develop if the sprinkler system was activated.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Staff Services, the sprinklers were observed.

Unit 1
At 2:41 p.m., the sprinkler by the storage room was contaminated with dust and lint.

Based on observation, the facility failed to provide a covered metal receptacle for emptying ashtrays in the smoking area. This could result in a fire, in the event an ashtray was emptied into a trash container. This affected all residents and staff who smoked in this area.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Support Services, the smoking areas were observed.

At 2:11 p.m., on the outpatient patio, there was no metal container for emptying ashtrays, in the smoking area. There were cigarette ashes in the patio trash can.

Based on observation, the facility failed to prevent the use of portable heaters in a health care facility. This was evidenced by a floor heater in an area where patients attend activities. This affected 1 of 6 smoke compartments and could result in injury to staff and patients.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Staff Services, the patient areas were observed.

At 3:52 p.m., there was a floor heater in the activity (AT) office. The office is located in the same area as the resident activity area. There was no information provided to indicate the heater temperature did not exceed 212 degrees Fahrenheit.

Based on observation, the facility failed to maintain the building electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. This was evidenced by the use of extension cords, by appliances that were plugged into surge protectors, by adapters with no surge protection, and by GFI switches that did not work. This could result in an increased risk of electrical shock or fire. This affected 3 of 6 smoke compartments.

NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 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: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Staff Services, the electrical wiring and equipment were observed. GFI (ground fault interrupter) type devices were located in various areas. The GFI de-energizes the circuit when the current to ground exceeds a predetermined value.

1. At 2:16 p.m., there was a refrigerator plugged into a surge protector, in the outpatient group therapist area.
2. At 2:21 p.m., the GFI (ground fault interrupter) failed to reset when tested, in the ladies' locker room by the gym.
3. At 2:22 p.m., the GFI failed to reset when tested, in the men's locker room by the gym.
4. At 2:30 p.m., there was an extension cord in use, in the business development office area. The extension cord was located near the first desk on the left.
5. At 2:36 p.m., in the CFO office, the refrigerator was plugged into a surge protector.

Unit 2 A
6. At 3:28 p.m., there was a 6 plug adapter, with no surge protection, connected and in use in the supply room.
7. At 3:46 p.m., there was an extension cord connected and in use, in the medical records office.
8. At 3:55 p.m., in the case management office, the refrigerator was plugged into a surge protector.
9. At 3:57 p.m., in housekeeping, the refrigerator was plugged into a surge protector.

Based on document review and interview, the facility failed to provide a Fire Watch policy that included notifications to the Department of Public Health and staff assignments. This affected 6 of 6 smoke compartments and could result in a delay in implementation of a fire watch, in the event of fire alarm or sprinkler system failure.

Findings:

On June 19, 2012, at 11:03 a.m., during document review with the Director of Staff Services, the Interim Life Safety Measures were reviewed. The Fire Watch policy did not include notification of the California Department of Public Health, in the event the fire alarm or automatic sprinkler system were out of service 4 hours or more in a 24 hour period. The policy also failed to have staff assignments indicating who would conduct the fire watch.

Based on observation the facility failed to ensure that Alcohol Based Hand Rub Dispensers (ABHR) were not installed above or adjacent to an ignition source. This affected 2 of 6 smoke compartments and could result in a fire.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Support Services, ABHR dispensers were observed in the facility.

June 19, 2012
1. At 2:30 p.m., the ABHR was installed above the light switch in the Business Development Office.

Unit 2 B
2. At 3:17 p.m., the ABHR was installed adjacent to the light switch in the staff lounge.

3. At 3:19 p.m., the ABHR was installed adjacent to the light switch in the exam room.

Unit 2 A
4. At 3:20 p.m., the ABHR was installed adjacent to a light switch in the medication room.

Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in walls. This could result in the passage of smoke and flames in the event of a fire. This affected 2 of 6 smoke compartments.

Findings:

During a tour of the facility with the Director of Support Services, on June 19 and June 20, 2012, the walls and ceilings were observed.

Unit 1
1. At 2:40 p.m., there was an approximately 4 inch penetration, on the right wall, in the clean linen room.
2. At 2:43 p.m., there was an approximately 1 inch penetration in the staff breakroom, behind the door, by the time clock.
3. At 2:45 p.m., in the medication room, there were 11 approximately 1/8 inch to 1/4 inch penetrations, on the back wall.
4. At 2:47 p.m., there were 2 approximately 1/4 inch penetrations, in Room 102, above the sink.

Unit 2-B
5. At 3:18 p.m., there were 2 approximately 3/4 inch penetrations on the left wall, in the storage room.

Unit 3
6. At 3:39 p.m., there were 5 approximately 1/4 inch to 1/2 inch penetrations on the back wall in the Lab Storage area.
7. At 3:40 p.m., in the medication room the corridor wall had an approximately 1/4 inch penetration.
8. At 3:43 p.m., there was an approximately 2 inch penetration on the back wall in the seclusion bathroom.
9. At 4:03 p.m., there were three approximately 3/4 inch penetrations and three approximately 1/8 inch penetrations on the right wall of the maintenance office.

Based on observation, the facility failed to maintain the corridor walls to resist the passage of smoke in the event of a fire. This was evidenced by penetrations in corridor walls. This affected 2 of 6 smoke compartments and could result in the passage of smoke and flames.

Findings:

On June 19, and June 20, 2012, during a tour of the facility with the Director of Support Services, the corridor walls were observed.

June 20, 2012
1. At 9:50 a.m., the corridor wall outside the cafeteria had an approximately 3 foot by 3 foot cut out in the 1 hour wall.
2. At 9:55 a.m., the corridor wall by the assessment office had an approximately 3 inch pipe unsealed at each end.

Based on observation, the facility failed to maintain the doors protecting corridor openings. This was evidenced by doors that were obstructed from closing and doors that failed to latch. This affected 3 of 6 smoke compartments and could result in the passage of smoke and flames in the event of a fire.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Support Services, the doors were observed.

June 19, 2012
1. At 2:26 p.m., the door to Consult Room B was obstructed from closing by a chair placed in front of the door.
2. At 2:38 p.m., the door to Consult Room C was obstructed from closing by a chair placed in front of the door.

Unit 3
3. At 3:40 p.m., the medication room door was held open with a wedge.
4. At 4:07 p.m., in the kitchen, the locker room door failed to latch after closing.

Based on observation, the facility failed to maintain the smoke barrier walls in 5 of 6 smoke compartments. This could result in the passage of smoke and flames from one smoke compartment to another in the event of a fire.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Support Services, the smoke barrier walls were observed.

June 20, 2012
1. At 9:46 a.m., there was an approximately 6 inch pipe around communication wires in the smoke barrier wall by AT. The pipe was not sealed on either side of the smoke barrier.

2. At 9:48 a.m., there was an approximately 4 inch penetration in the smoke barrier by the cafeteria.

3. At 9:55 a.m., there was an approximately 5 inch pipe sleeve in the smoke barrier wall by the assessment area. The pipe sleeve was not sealed.

4. At 9:58 a.m., the smoke barrier by the gym had an approximately 1 inch penetration along the left side of a pipe in the center of the wall.

Unit 3
5. At 10:37 a.m., there was an approximately 2 inch penetration in the smoke barrier wall by Room 222.

Based on observation and interview, the facility failed to maintain the battery operated emergency lights on 3 of 5 patios. This was evidenced by no records for monthly and annual testing for the emergency lights. This could result in a delay of evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performers a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Staff Services, the emergency lights were observed.

June 19, 2012 - Unit 1
1. At 2:55 p.m., on the patio there were two emergency battery operated lights. During an interview, the Director of Support Services stated he does not test the lights. The lights were installed by a vendor, when they did an expansion, because the vendor had equipment and supplies on the patios.

Unit 2 B
2. At 3:12 p.m., the patio had two emergency battery operated lights. The Director of Support Services reported there was no documentation for testing the lights monthly or annually. The lights were not tested.

Unit 2 A
3. At 3:25 p.m., the patio had three emergency battery operated lights. There was no documentation for testing the lights monthly or annually.

During the survey the lights could not be tested. There was a protective cover that was placed over the lights.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. This was evidenced by one sprinkler that was coated with dust and lint. This affected 1 of 6 smoke compartments and could result in the failure of the sprinkler pattern to develop if the sprinkler system was activated.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Staff Services, the sprinklers were observed.

Unit 1
At 2:41 p.m., the sprinkler by the storage room was contaminated with dust and lint.

Based on observation, the facility failed to provide a covered metal receptacle for emptying ashtrays in the smoking area. This could result in a fire, in the event an ashtray was emptied into a trash container. This affected all residents and staff who smoked in this area.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Support Services, the smoking areas were observed.

At 2:11 p.m., on the outpatient patio, there was no metal container for emptying ashtrays, in the smoking area. There were cigarette ashes in the patio trash can.

Based on observation, the facility failed to prevent the use of portable heaters in a health care facility. This was evidenced by a floor heater in an area where patients attend activities. This affected 1 of 6 smoke compartments and could result in injury to staff and patients.

Findings:

On June 19, 2012, during a tour of the facility with the Director of Staff Services, the patient areas were observed.

At 3:52 p.m., there was a floor heater in the activity (AT) office. The office is located in the same area as the resident activity area. There was no information provided to indicate the heater temperature did not exceed 212 degrees Fahrenheit.

Based on observation, the facility failed to maintain the building electrical wiring and equipment in accordance with NFPA 70, National Electrical Code. This was evidenced by the use of extension cords, by appliances that were plugged into surge protectors, by adapters with no surge protection, and by GFI switches that did not work. This could result in an increased risk of electrical shock or fire. This affected 3 of 6 smoke compartments.

NEC 70, National Electrical Code, 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 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: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the
provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On June 19 and June 20, 2012, during a tour of the facility with the Director of Staff Services, the electrical wiring and equipment were observed. GFI (ground fault interrupter) type devices were located in various areas. The GFI de-energizes the circuit when the current to ground exceeds a predetermined value.

1. At 2:16 p.m., there was a refrigerator plugged into a surge protector, in the outpatient group therapist area.
2. At 2:21 p.m., the GFI (ground fault interrupter) failed to reset when tested, in the ladies' locker room by the gym.
3. At 2:22 p.m., the GFI failed to reset when tested, in the men's locker room by the gym.
4. At 2:30 p.m., there was an extension cord in use, in the business development office area. The extension cord was located near the first desk on the left.
5. At 2:36 p.m., in the CFO office, the refrigerator was plugged into a surge protector.

Unit 2 A
6. At 3:28 p.m., there was a 6 plug adapter, with no surge protection, connected and in use in the supply room.
7. At 3:46 p.m., there was an extension cord connected and in use, in the medical records office.
8. At 3:55 p.m., in the case management office, the refrigerator was plugged into a surge protector.
9. At 3:57 p.m., in housekeeping, the refrigerator was plugged into a surge protector.

Based on document review and interview, the facility failed to provide a Fire Watch policy that included notifications to the Department of Public Health and staff assignments. This affected 6 of 6 smoke compartments and could result in a delay in implementation of a fire watch, in the event of fire alarm or sprinkler system failure.

Findings:

On June 19, 2012, at 11:03 a.m., during document review with the Director of Staff Services, the Interim Life Safety Measures were reviewed. The Fire Watch policy did not include notification of the California Department of Public Health, in the event the fire alarm or automatic sprinkler system were out of service 4 hours or more in a 24 hour period. The policy also failed to have staff assignments indicating who would conduct the fire watch.