Facility Fails to Maintain Sprinkler System
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting the entire facility. Documentation reviewed on March 12, 2025, revealed that only two quarterly external water tank inspections and two quarterly wet sprinkler inspections were recorded for the year 2024. During an exit interview, the Administrator, Director of Maintenance, and Assistant confirmed the absence of necessary report documentation. Additionally, the 4th quarter sprinkler inspection report from December 23, 2024, indicated several issues: a corroded sprinkler in the Dietary area needed replacement, a hydro test for the fire department connection was pending, and the fire pump room's temperature was below the required 40 degrees Fahrenheit, risking pipe damage due to potential freezing. Furthermore, the facility was advised to monitor and maintain the water level in the tank consistently. Observations made on March 12, 2025, revealed additional deficiencies. Two sprinkler heads in the basement laundry chute room were recessed into the ceiling, potentially hindering immediate water spread. Moreover, the fire alarm panel indicated a supervisory alert for low water in the water tower. These findings were confirmed during an exit interview with the facility's administration and maintenance team, highlighting the facility's failure to ensure proper maintenance and functionality of its sprinkler system.
Plan Of Correction
1. The Sprinkler system will be scheduled with Tustin for testing annually. Sprinkler heads will be adjusted. At the time of the survey, the fire pump was in test mode and was discharging water, and the facility ensures proper water is filled in the water tower. The facility will inspect the external water tank at least quarterly. 2. A. Facility will schedule replacement sprinkler with Tustin. B. Facility will contact the fire department to get hydro test scheduled. C. Report was from 2024. The temperatures were good during the site visit on 3/12/25. D. Facility currently monitors the water tank daily. E. Water was flowing during the site visit on 3/12/25. 3. Tustin will be scheduled to come in and turn sprinkler heads downwards. 4. The fire alarm panel is working properly and was completing a test which led to the low water notification. The facility has a working heater that maintains adequate temperature throughout.