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Based on observation and interview the facility staff failed to ensure a self-closing door fully closed.

The deficiency had the potential to delay the closing of the doors in the event of a fire, creating a condition conducive to the spread of fire, smoke, and heat.

Finding:

On 2/21/18 between 9:14 a.m. and 9:30 a.m., the self-closing corridor door at Equipment room 1 failed to fully self-close to latch at the lower level operating room (OR) in the Main Hospital.

During an interview at the same time as the observation the Administrative Facilities Director stated the door needed to be adjusted.

NFPA 72 National Fire Alarm and Signaling Code 2010 Edition

1.1.1 NFPA 72 covers the application, installation, location, performance, inspection, testing, and maintenance of fire alarm systems, supervising station alarm systems, public emergency alarm reporting systems, fire warning equipment and emergency communications systems (ECS), and their components.

3.1 General. The definitions contained in this chapter shall apply to the terms used in this Code. Where terms are not defined in this chapter or within another chapter, they shall be defined using their ordinarily accepted meanings within the context in which they are used. Merriam-Webster's Collegiate Dictionary, 11th edition, shall be the source for the ordinarily
accepted meaning.

3.3.106 Frequency. Minimum and maximum time between events (SIG-TMS).
3.3.106.1 Weekly Frequency. Fifty-two times per year, once per calendar week.
3.3.106.2 Monthly Frequency. Twelve times per year, once per calendar month.
3.3.106.3 Quarterly Frequency. Four times per year with a minimum of 2 months, maximum of 4 months.
3.3.106.4 Semiannual Frequency. Twice per year with a minimum of 4 months, maximum of 8 months.
3.3.106.5 Annual Frequency. Once per year with a minimum of 9 months, maximum 15 months.

10.5.9.1.1 Batteries shall be marked with the month and year of manufacture using the month/year format.

10.5.9.1.2 Where the battery is not marked with the month/year by the manufacturer, the installer shall obtain the date code and mark the battery with the month/year of battery manufacture.

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 (Replace battery within 5 years after manufacture or more frequently as needed.)

This Code was not met as evidenced by:

Based on observation, interview and document review the facility staff failed to ensure the fire alarm system was maintained per NFPA 72 by not having batteries dated.

Maintenance of the fire alarm system assists in ensuring that the fire alarm system will function as designed in the event of a fire emergency.

Finding:

On 2/22/18 at 10 a.m., at PT/OT Outpatient in La Mirada, two of two sealed lead acid batteries in the fire alarm panel were not dated.

At the same time as the observation the Facilities Maintenance Manager acknowledged the batteries were not dated and stated that the batteries should have been dated.

NFPA 13: Standard for the Installation of Sprinkler Systems 2010 Edition

8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, 8.5.6.5 are met the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Standard was not met as evidenced by:

Based on observation the facility staff failed to maintain sprinklers in accordance with NFPA 13, by having a obstruction less than 18 in. below a sprinkler deflector.

Continuous and non-continuous avoidable obstructions can prevent the proper sprinkler discharge pattern from developing and reaching the protected hazard. In the event of a fire emergency, unobstructed areas below sprinkler deflectors help ensure the sprinkler will perform as designed. The deficiency affected one of two smoke compartments on the first floor and one of one smoke compartment in the basement.

Finding:

On 2/21/18 at 2:58 p.m., there was storage of instrument packs with less than an 18 inch clearance between the sprinkler deflector and the top of storage at the instrument packet storage room at the lower level OR in the Main Hospital.

During interviews at the same time as the observations the Administrative Facilities Director acknowledged the storage had less than an 18 inch clearance from the sprinkler deflectors.