Failure to Notify Authorities and Maintain Fire Protection System
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors when the fire protection system became nonfunctional for a period of several days. During this time, all fire exit doors were closed as a precaution, and a fire watch was initiated by the Maintenance Supervisor and other staff, with hourly inspections documented. However, the facility did not notify the California Department of Public Health (CDPH) or the California Department of Healthcare Access and Information (HCAI) about the fire protection system malfunction, as required by regulations. The Administrator confirmed that the facility remained under a fire watch and acknowledged unawareness of the notification requirement. Review of facility documents and policies indicated that the fire alarm system is expected to be operable at all times and that maintenance personnel are responsible for keeping the fire alarm system in good working order. The facility's fire watch log and maintenance policies further outlined the procedures to be followed in the event of a system outage, including the implementation of a fire watch. Despite these documented procedures, the required notifications to regulatory agencies were not made during the period when the fire protection system was out of service.