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Based on observation and staff interviews, the facility failed to assure that all of the required areas are sprinklered, failing to meet the building construction requirements for 1 of 14 smoke zones. The facility has a capacity of 69 with a census of 14.

Findings Include:

During the tour starting on 11-17-2014 and ending on 11/19/2014, the following is observed:

--1. On 11/17/2014 at 1:17 P.M., the lower level kitchen area has a blast chiller room with no sprinkler coverage.

The Engineering And Environmental Services Director was present and acknowledge the finding.

NFPA Standard: One story is permitted for an unprotected noncombustible type building protected with a complete automatic sprinkler system. 2000 NFPA 101, Table 18.1.6.2

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the attic area, affecting 1 of 14 smoke zones. The facility has a capacity of 69 with a census of 14.

Findings Include:

During the tour starting on 11-17-2014 and ending on 11/19/2014, the following is observed:

--1. On 11/17/2014 at 11:58 A.M., in the electrical room #2330, there is a gap around the blue and white cables on 2 walls.

The Engineering And Environmental Services Director was present and acknowledge the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting ceilings, partitions, and doors. The doors shall be self closing or automatic closing. 2000 NFPA 101.

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors including the exit discharge. This deficient practice fails to ensure that all areas of egress will not be left in total darkness, affecting 1 of 14 smoke zones. The facility has a capacity of 69 with a census of 14.

Findings Include:

During the tour starting on 11-17-2014 and ending on 11/19/2014, the following is observed:

--1. On 11/17/2014 at 2:50 P.M., the lower level exit door by the Health For Life Room, the 2 light fixture outside has one light bulb not working.

The Engineering And Environmental Services Director was present and acknowledge the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff 's inability to respond in the event of an emergency, affecting 14 out of 14 smoke zones. The facility has a capacity of 69 with a census of 14.

Findings Include:

During record reviews starting on 11-17-2014 and ending on 11/19/2014, the following is observed:

--1. On 11/17/2014 at 4:44 P.M., record reviews shows no documentation of a fire drill for the 7:00 P.M. to 7:00 A.M. shift during the April to June of 2014 quarter.

The Engineering And Environmental Services Director was present and acknowledge the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2