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Permit Details

Status:
Final
Type:
State Lic Facls Annual Insp
Address:
1780 W ANKLAM RD
Apply Date:
12/08/2016
Applicant:
DAVITA DIALYSIS
Description:
Dialysis Clinic -34 beds

Completed Inspections

Permit Status: Final
Permit Number: T16FO00143
Permit Description: Dialysis Clinic -34 beds
Total Completed Inspections - 1
Date Description Inspector Results Comments
10/05/2016 FIRE INSP - STATE LICENSE nspreng1 Approved TFC 604.3 Maintenance of emergency power systems. Emergency and standby power systems shall be maintained in accordance with NFPA 110 and NFPA 111 such that the system is capable of supplying service within the time specified for the type and duration required.
1) You shall provide paperwork from the last system service of your backup generator and show records of weekly start up and monthly tests of the generator including transfer switches and time to transfer of power. (Also required by TFC 604.3.2 - 604.4.1)

YEARLY TEST

TFC 604.5.2 Power test. For battery-powered emergency lighting, A power test of the emergency lighting equipment shall be completed annually. The power test shall operate the emergency lighting for a minimum of 90 minutes and shall remain sufficiently illuminated for the duration of the test.
TFC 604.5.2.1 Power test record. Records shall be maintained on the premises for a minimum of three years and submitted to the fire code official upon request. The record shall include the location of the emergency lighting tested, whether the unit passed or failed, the date of the test, and the person completing
the test.
1) You shall perform an annual test of the battery powered emergency lighting that is on daycare/school property (including all areas that students, children in care, staff and teachers function within routinely), documenting the location of each, pass or fail, test date, and person completing test. This record shall be maintained and presented to the fire inspector upon request at the next inspection of your facility.







TFC 1011.6.3 Exit Sign Power source. Exit signs shall be illuminated at all times. To ensure continued illumination for a duration of not less than 90 minutes in case of primary power loss, the sign illumination means shall be connected to an emergency power system provided from storage batteries, unit equipment or an on-site generator. The installation of the emergency power system shall be in accordance with Section 604. (see testing procedures above in 604.5.1-604.5.2.1)
Exception: Approved exit sign illumination means that provide continuous illumination independent of external power sources for a duration of not less than 90 minutes, in case of primary power loss, are not required to be connected to an emergency electrical system.
1) You shall perform monthly and annual tests of the backup power supply to your exit signs that are on daycare/school property (including all areas that students, children in care, staff and teachers function within routinely), documenting the location of each, pass or fail, test date, and person completing test. This record shall be maintained and presented to the fire inspector upon request at the next inspection of your facility.

TFC 1008.1.9 Door operations. Except as specifically permitted by this section egress doors shall be readily openable from the egress side without the use of a key or special knowledge or effort.
1) There is a keypad to egress into the employee hallway between chairs 10 and 9 in the main dialysis room. This is not an exit, as it requires special knowledge to open this door and the door does not swing in the direction of travel. This is an employee access door only and You shall remove the exit sign above this door. There are two other marked exits that may be accessed by public and employees.
2) Break room door may NOT require a key to egress.

TFC 703.2 Opening protectives. Opening protectives shall be maintained in an operative condition in accordance with NFPA 80. Where allowed by the fire code official, the application of field-applied labels associated with the maintenance of opening protectives shall follow the requirements of the approved third-party certification organization accredited for listing the opening protective. Fire doors and smoke barrier doors shall not be blocked or obstructed, or otherwise made inoperable. Fusible links shall be replaced promptly whenever fused or damaged. Fire door assemblies shall not be modified.
1) Where ever a UL listed fire label has been painted over, the door shall either be replaced with a like listed fire rated door or the label shall be made to be readable by the fire inspector. (nutritionist, where house door/frame, Break room, and where ever else painted).




TFC 703.2.3 Door operation. Swinging fire doors shall close from the full-open position and latch automatically. The door closer shall exert enough force to close and latch the door from any partially open position.

1) The nutritionist room door and several other doors have pedestal type door stops on them to hold the door open. These doors are Fire Rated doors and are not allowed to have door stops on them. The only devices acceptable for holding fire doors open are fire-detector-activated automatic-closing devices that automatically close the doors (or allow the doors to swing closed using self-closing devices) in the event of a fire. Numerous devices, such as electromagnetic hold-opens, pneumatic systems and systems of pulleys and weights connected to a fusible link, are available.

TFC 1030.2 Reliability. Required exit accesses, exits and exit discharges
shall be continuously maintained free from obstructions or impediments to full instant use in the case of fire or other emergency when the building area served by the means of egress is occupied. An exit or exit passageway shall not be
used for any purpose that interferes with a means of egress.
1) You shall cause your Comm room exit door to the outside to operate with no extra effort or force (it is currently sticky).
2) There is no handle to get out of the exterior bio-hazard waste area. There are marked exits that lead to this area. You shall provide a gate/handle that does not require the use of special knowledge or a key to exit from.

TFC 906.2 General requirements. Portable fire extinguishers shall be selected, installed and maintained in accordance with this section and NFPA 10.
1) You shall have all of your fire extinguishers serviced and tagged as such.

TFC 901.6.2 Records. Records of all system inspections, tests and
maintenance required by the referenced standards shall be maintained on the premises for a minimum of three years and shall be copied to the fire code official upon request.
1) Your stock room riser is tagged as needing a 5 year check valve test and 5 year guage test. You shall provide the fire inspector with a copy of your most recent fire sprinkler system annual inspection report.