Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents Affected
Exit doors in newly licensed facilities shall be at least thirty-six inches (36") wide, at least seventy-two inches (72") high and shall swing outward. II/III 7/18/2022   
Exits, Stairways, and Fire Escapes. (E) If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. I/II 7/18/2022   
Complete Fire Alarm Systems. (A) All facilities shall have a complete fire alarm system installed in accordance with NFPA 101, Section 18.3.4, 2000 edition. The complete fire alarm shall automatically transmit to the fire department, dispatching agency, or central monitoring company. The complete fire alarm system shall include visual signals and audible alarms that can be heard throughout the building and a main panel that interconnects all alarm-activating devices and audible signals. Manual pull stations shall be installed at or near each required attendant ' s station and each required exit. I/II 2. For facilities with a sprinkler system in accordance with NFPA 13R, 1999 edition, smoke detectors interconnected to the complete fire alarm system shall be installed in all corridors, spaces open to corridors, and in accessible spaces not protected by the sprinkler system, as required by NFPA 72, 1999 edition. Smoke detectors shall be no more than thirty feet (30') apart with no point on the ceiling more than twenty-one feet (21') from a smoke detector. Smoke detectors shall not be installed in areas where environmental influences may cause nuisance alarms. Such areas include, but are not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. In these areas, heat detectors interconnected to the complete fire alarm system shall be installed. Bathrooms not exceeding fifty-five (55) square feet and clothes closets, linen closets, and pantries not exceeding twenty-four (24) square feet are exempt from having any detection device if the walls and ceilings are surfaced with limited-combustible or non-combustible material as defined in NFPA 101, 2000 edition. Concealed spaces of noncombustible or limited combustible construction are not required to have detection devices. These spaces may have limited access but cannot be occupied or used for storage. I/II 7/18/2022   
Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II 7/18/2022   
Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II 7/18/2022   
Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. I/II 7/18/2022   
The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III 7/18/2022   
Gas-fired water heaters shall be properly installed and vented and all water heaters shall be equipped with a temperature and pressure relief valve. II 7/18/2022