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K0345
F

Failure to Document Semi-Annual Fire Alarm Battery Testing

Ontario, California Survey Completed on 06-17-2025

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 the fire alarm system in accordance with regulatory requirements, as evidenced by the lack of documentation for one of the required semi-annual fire alarm control panel battery load voltage tests. During a document review and interview, the Maintenance Director and Assistant Administrator were unable to provide records for this testing and stated they were not aware of the requirement. This deficiency affected both smoke compartments and all residents in the facility. The absence of documentation for the semi-annual battery testing was identified during a review of facility records and confirmed through staff interviews. No issues were reported with the fire alarm system itself at the time of the survey, but the required testing and documentation were not completed as mandated by NFPA 101 and NFPA 72 standards.

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