Automatic Sprinkler System Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in two of the 15 smoke compartments. During an observation on April 14, 2025, two specific issues were identified: a gap larger than 1/8 inch was found around two sprinkler heads with escutcheons in a storage room inside the Inventory Control room, and a ceiling tile track hangar wire was attached to a sprinkler branch line above the smoke doors near the 2 South Supervisor's office. These deficiencies were confirmed through an interview with the Assistant Facility Administrator and Maintenance Director on April 15, 2025.
Plan Of Correction
Large gap around two sprinkler pipes with escutcheons in the inventory control storage room. Ceiling hanger wire attached to sprinkler branch line above smoke door near 2 south supervisors office. Maintenance adjusted hanger in ceiling to raise the sprinkler head and escutcheon closer to the ceiling tile and replaced the ceiling tile. Maintenance removed hanger from sprinkler. Maintenance conducted audit of facility with no other issues with sprinklers or escutcheons. The maintenance department will be educated on Sprinkler system compliance. Audits will be completed by maintenance to ensure sprinkler system is in compliance, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.