Observations
Based on a review of the facility fire drill log and staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill logs were reviewed from December 2025 through June 2026.
The facility fire drill log indicated fire drills were conducted in December 2025, January 2026, and February 2026. However, staff interview confirmed that no fire alarm or smoke detector was set off during these fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency has been resolved through ETHOS obtaining the appropriate exception from the Department of Drug and Alcohol Programs (DDAP) related to the activation of the building's fire alarm/smoke detection system during fire drills.
The building/property management is responsible for the ongoing monitoring, inspection, and testing of the fire alarm and smoke detection equipment in accordance with applicable requirements. The building will provide ETHOS with documentation verifying that the applicable systems and equipment have been monitored and tested as required.
ETHOS' Director of Compliance will maintain the documentation provided by the building in its facility records and will make such documentation available for review during future licensing inspections. The facility will continue to comply with the terms and conditions of the DDAP-approved exception. |