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K0345
F

Failure to Transmit Fire Alarm Signals to Central Station

Santa Paula, California Survey Completed on 04-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During a tour, observation, and record review, it was found that the fire alarm system did not transmit fire signals to a central station when initiating devices were activated. Three devices were tested within a specific time frame, and none of the alarm signals were received by the central station. The Maintenance Supervisor confirmed during an interview that after testing the devices, he contacted the central station, which verified that no trouble signal had been received. This failure to transmit alarm signals was directly observed and documented during the survey process. The deficiency affected all 79 residents in the facility, spanning three smoke compartments. The Assistant Administrator confirmed the issue and attributed the problem to a possible phone service provider issue, but at the time of the survey, the fire alarm system was not functioning as required to ensure prompt transmission of fire signals to the central station.

Plan Of Correction

K 345 K345 Fire Alarm System - Testing and Maintenance K345 CORRECTIVE ACTION: ADON/Maintenance upon discovery of the alarm testing signal transmission failure to service provider: Fire watch protocols were activated per facility policy. SEE EXHIBIT - A - Fire alarm service provider (Bay Alarm) dispatch was contacted to follow up on the testing transmission disruption. - Facilities IT and telephone service provided (Frontier) were contacted to troubleshoot the communication lines. - SEE EXHIBIT - B - Bay Alarm technician inspected fire alarm panel on and reported that it was in good functioning order. - Technician referred our maintenance team to follow up with our phone service provider. K345 CORRECTIVE ACTION: ADON/Maintenance upon discovery of the alarm testing signal transmission failure to service provider: Fire watch protocols were activated per facility policy. SEE EXHIBIT - A - Fire alarm service provider (Bay Alarm) dispatch was contacted to follow up on the testing transmission disruption. - Facilities IT and telephone service provided (Frontier) were contacted to troubleshoot the communication lines. - SEE EXHIBIT - B - Telephone service provider technician inspected the telephone lines and reported that one of the land lines likely had physical damage. - Technician re-routed the landline and re-established connection to the fire alarm panel. - While technician was in the building, our maintenance team reached out to Bay Alarm to inform their central monitoring station that a test of the system would be performed. - Bay Alarm emailed the test report confirming that the test signal was received. - SEE EXHIBIT - C IDENTIFICATION OF OTHERS: Maintenance Dept/Designees were inserviced to include the monthly testing results in the monthly quality assurance meeting report. Designee will also include communication with the central station prior to system testing and include confirmation of patent signal in the monthly report. - SEE EXHIBIT - D MEASURES TO PREVENT RECURRENCE: Maintenance Dept/Designees were inserviced to inform administration during daily department manager morning meeting/report whenever testing is taking place to ensure administration is able to monitor the testing and confirm successful testing and transmission to providers' Central Station. - SEE EXHIBIT - E

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