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)
|
Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain the allowable gap margins on rated/labeled doors, in one of three smoke compartments within the component.
Findings include:
1. Observation on March 3, 2024, at 11:30 AM, revealed the rated doors to both storage rooms in the corridor, between the Kitchen and Staff Dining, had gaps greater than 3/16 inch.
Interview with the Director of Maintenance on March 3, 2024, at 11:30 AM, confirmed the rated doors exceeded the allowable gap margins.
| | Plan of Correction - To be completed: 04/25/2024
1. Crown Fire Dorr Stop was added to each door to seal the gap greater than 3/16 inches. 2. Maintenace staff educated on doors with gaps greater than 3/16th inches. 3. Audits will be completed monthly times 3 months then quarterly for the next year on door gaps and reported to QAPI monthly.
|
|