Observations
Based on a review of the facility fire drill log and staff interview, the facility failed to provide documentation that the fire alarm system is in working order.
Fire drill logs were reviewed from September 2025 through July 2026.
At the time of inspection, the facility had an active exception that allows an alternate means of announcing fire drills to alert those within the space occupied by the facility of the fire drill instead of activating the fire alarm system for each fire drill. Since the fire alarm system will not be activated during fire drills, the facility is required to provide documentation during licensing inspections that shows that the fire alarm system is in working order, updated on an annual basis.
Fire drill logs confirmed that the facility conducted fire drills monthly between September 2025 through July 2026. However, the facility was unable to provide documentation that the fire alarm system is in working order.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For future inspections, the Compliance Officer will contact the building owner of which NFRC holds their office and request a copy of the current alarm system inspection, which will be provided by the Compliance Officer at our next inspection in 2027 and years forward. The inspection will document that the fire alarm system is in working order. |