Deficiency in Commercial Cooking Hood Suppression System
Penalty
Summary
The facility failed to maintain its commercial cooking facility in accordance with NFPA 101 standards. During a fire safety tour, it was observed that the seams of the kitchen's commercial cooking hood suppression system were not sealed or made greasetight. This deficiency was identified during an inspection conducted on February 4, 2025, at 11:09 AM, with the Maintenance Director present. The Maintenance Director acknowledged the findings during an interview conducted concurrently with the observations. The issue was further reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference on the same day at 2:40 PM. The report cites specific sections of NFPA 96 and NFPA 101 that were not adhered to, indicating a failure to comply with the required fire safety standards for commercial cooking operations.
Plan Of Correction
Corrective Actions The facility's kitchen hood seams were sealed to ensure that the kitchen hood was grease tight on 2/5/2025. Identification of Others Potentially Affected The facility only has one kitchen hood, so no further evaluations are needed. Systemic Changes The Maintenance Director, or designee, will continue to perform documented monthly inspections of the facility's kitchen hood to ensure the kitchen hood seams remain sealed and grease tight on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly kitchen hood inspections will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met.