Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on February 10, 2025, at 12:20 p.m., a surveyor identified an unsealed penetration around data wires located above the smoke doors on the first floor, section D-1. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that day at 1:45 p.m.
Plan Of Correction
The penetration around data wires above smoke doors on D1 was sealed using LC Endothermic Firestop Sealant. System number CAJ0047 with an F rating of 2 hours and a T rating of 2 hours. The maintenance team filled the void in accordance with manufacturers specifications. The maintenance department will check behind work orders/vendors to ensure all penetrations are sealed properly. The maintenance director will in-service staff on maintaining smoke barrier walls free of unsealed penetrations. Random weekly audits of smoke barrier walls will be conducted X3 weeks and findings will be reported to QAPI.