Initial Comments:
Name - WONDER KIDS Component - 01
Facility ID# 23844001
Component 1
Main Building
Based on a Relicensure Survey completed on July 10, 2023, it was determined that Wonder Kids Medical Daycare Llc was not in compliance with the following requirements of the Life Safety Code for an existing pediatric extended care health care occupancy.
This is a one-story, Type V (000), unprotected wood frame structure, which is fully sprinklered.
Plan of Correction:
28 Pa. Code § 569.2 STANDARD
Sprinkler System - Maintenance and Testing
Name - WONDER KIDS Component - 01
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on document review, observation and interview, it was determined the facility failed to provide quarterly sprinkler maintenance documentation, affecting the entire component.
Findings include:
1. Review of documentation on July 10, 2023, between 9:00 AM and 9:06 AM, revealed the facility lacked documentation for the following:
a. 9:00 AM, Wet and Dry System, 4th quarter of 2022;
b. 9:03 AM. Wet and Dry System, 3rd quarter of 2022;
c. 9:06 AM, Wet and Dry System, 2nd quarter of 2023.
Interview at the time of the exit conference with the Administrator on July 10, 2023, at 11:45 AM, confirmed the lack of documentation.
Plan of Correction:It was the 1st quarter of 2023 that was in question, not the 2nd.
Sprinkler inspection company has already produced and provided to facility, separate inspection reports for the quarterly inspections for 9/22, 12/22 and 3/23. The information is no longer combined with/embedded in the fire alarm forms. They have also internally recoded this facility's inspection to generate two separate forms. Sprinkler company has been provided with the Administrator's direct email with the instruction that all reports will be emailed directly to Administrator upon completion of inspections for review.
Administrator has added a "quarterly fire alarm inspection reports present" to the monthly checklist of emergency equipment.
Administrator has added "quarterly sprinkler inspection reports present" to the monthly checklist of emergency equipment.
Administrator will address the status of the reports at quarterly QA meetings.
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