Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain hazardous area doors to meet minimum gap requirements, and to positively latch in frame, affecting two of six smoke zones within the component.
Findings include:
1. Observation on August 20, 2025, at 11:47 AM, revealed the 1st floor, Elevator Machinery Room door exceeded minimum gap requirements, at the top and latch side, of 1/8th inch.
Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the Elevator Machinery Room door exceeded minimum gap requirements.
2. Observation on August 20, 2025, at 11:53 AM, revealed the 1st floor, Service Hall door, by Staff Locker Room, failed to positively latch, due to faulty panic hardware.
Interview at the time of the exit conference with the Regional Property Manager, Assistant Administrator and Maintenance Assistant on August 20, 2025, at 1:30 PM, confirmed the Service Hall door failed to positively latch in frame.
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Observation on November 18, 2025, at 11:30 AM, revealed item 1 had not been corrected.
Interview at the time of the exit conference with the Administrator and Maintenance on November 18, 2025, at 1:30 PM, confirmed item 1 had not been corrected.
| | Plan of Correction - To be completed: 12/02/2025
1. First Floor Service Hall door repaired to positively latch on 11/18/2025. A TLW is requested for correction of the Elevator Machine Room door that exceeds minimum gap requirements.
2. The maintenance Director or designee will audit all equipment room doors to validate compliance with minimum gap requirements.
3. The Administrator or designee will educate maintenance staff on K0321 and maintaining compliance with minimum gap requirements and positive latch to frame.
4. The Maintenance Director or designee will audit 5 hazardous area doors monthly for 12 months to validate compliance with minimum gap requirements. The Maintenance Director or designee will audit 5 hazardous area doors monthly for 12 months to validate compliance with positive latching.
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