VA Sepulveda_16111 Plummer St_Bldg 200_ANN FA_02-05-24_Redacted 12.pdf

Executive Summary Generated by: BuildingReports.com

Building Information Building: VA Sepulveda Bldg 200 Contact: Keith Hayhurst Address: 16111 Plummer St Phone: 310.714.5379 City/State/ZIP Code: North Hills, CA 90012 Mobile:

Country: United States of America Email: Keith.Hayhurst@VA.Gov

Inspection Performed By

System Control Unit Manufacturer: Cerberus Inspection Date: 02/01/2024 IDC Style:

Model Number: Pyrotronics - MXL Install Date: 03/03/2020 SLC Style:

Software Version: Version Date: 03/03/2020 NAC Style:

Location: 1st Main Lobby Entrance Atrium Current Protection:

Central Station Signal Verification Type: Digital Communicator Mfg.: Detection Systems Model #: DS9471 Test Time/Date: 2/1/24 9:17:50 AM Restore Time: 38 Seconds Note:

Certification Company: Building: VA Sepulveda Bldg 200 Inspector: Contact: Keith Hayhurst

Inspection Completion Date: Feb 5, 2024 Building: VA Sepulveda Bldg 200 EC 02.03.05 EP 02 Semi-annual testing of water flow devices and valve tamper switches. NFPA 72 (2022) Table 14.4.3.2

(17)(10)(a) & (17)(11)

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Tamper Switch 19 19 0 19 0 19 Waterflow Switch 9 9 0 9 0 9

EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors. NFPA 72 (2022) Table 14.4.3.2 (17)

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Duct Detector 27 27 0 27 0 27 Heat Detector 4 4 0 4 0 4 Pull Station 51 51 0 51 0 51 Smoke Detector 58 58 0 58 0 58

EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door releasing devices. NFPA 72 (2022) Table 14.4.3.2 (22)

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Horn/Strobe 4 4 0 4 0 4 Releasing Device 17 17 0 17 0 17 Speaker/Strobe 142 142 0 142 0 142 Strobe 67 67 0 67 0 67

EC 02.03.05 EP 05 Annual test of fire alarm equipment for notifying off-site fire responders. NFPA 72 (2022) Table 14.4.3.2 (4)

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Communicator 1 1 0 1 0 1

EC 02.03.05 EP 11 For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow. Fire pump supervisory signals for pump running and pump power loss are tested annually. NFPA 25 (2023) 8.3.3

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Fire Pump Trouble 1 1 0 1 0 1

EC 02.03.05 EP 19 Annual test of automatic smoke-detection shutdown devices for air-handling equipment. NFPA 90A (2024) 6.4.1

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Duct Detector 27 27 0 27 0 27

EC 02.03.05 EP 20 Annual operation and full closure of sliding and rolling fire and smoke barrier doors for proper operation and full closure. NFPA 80-2022 5.2.4.1; NFPA 105-2022 5.2.1; 5.2.2

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Roll Down Door 4 4 0 4 1 5

LS 02.01.34 EP 02 Protected master fire alarm control panel

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Control Panel 1 1 0 1 0 1

LS 02.01.34 EP 10 All other Life Safety Code fire alarm requirements related to NFPA 101 2024 18/19.3.4

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Battery 14 14 0 14 0 14

Expander Panel 1 1 0 1 0 1 Multi-Sensor Detector 2 2 0 2 0 2 Power Supply 6 6 0 6 0 6

LS 02.01.50 EP 07 Annual - Elevators are fully equipped and protected

Devices Tested This

Quarter Pass Fail Tested YTD

(2024) Untested YTD

(2024) Total Quantity Elevator 15 14 1 15 0 15 Total Device Count: 444

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Discrepancy Report Generated by: BuildingReports.com

Building: VA Sepulveda Bldg 200 Control Panel: 1 - Cerberus Pyrotronics - MXL The Discrepancy Report consolidates each discrepancy listed within the various Testing sections of your Inspection.

Discrepancies are listed by Category, and grouped by device type. The description of the problem is provided and where appropriate, code references are listed for your convenience. Any item that was inspected that is subject to a recall or part of a manufacturer's replacement/upgrade program is included.

ScanID Location Problem Address Reference

LS 02.01.50 EP 07 Annual - Elevators are fully equipped and protected

Elevator 57079665 1st Elevator Machine Room 1550 By Men’s

Restroom 155 Failed Operation 1 NFPA72 14.2.2.2.2

Code References NFPA72 14.2.2.2.2 System deficiencies shall be corrected.

Notes & Recommendations Generated by: BuildingReports.com

Building: VA Sepulveda Bldg 200 Control Panel: 1 - Cerberus Pyrotronics - MXL

The Notes & Recommendations Report details additional inspection notes made by the Inspectors during the course of the building inspection.

ScanID Note Device Type Location Comment EC 02.03.05 EP 02 Semi-annual testing of water flow devices and valve tamper switches. NFPA 72 (2022) Table 14.4.3.2 (17)(10)(a) & (17)(11)

57079707 1 Tamper Switch 1st Fire Pump Room 1113B (N/C) Passed Normally Closed.

57079713 2 Tamper Switch 1st Fire Pump Room 1113B (N/C) Passed Normally Closed.

57079714 3 Tamper Switch 1st Fire Pump Room 1113B (N/C) Passed Normally Closed.

EC 02.03.05 EP 20 Annual operation and full closure of sliding and rolling fire and smoke barrier doors for proper operation and full closure. NFPA 80-2022 5.2.4.1; NFPA 105-2022 5.2.1; 5.2.2

57079674 4 Roll Down Door 1st Laboratory 1900 Entrance Not in service

LS 02.01.50 EP 07 Annual - Elevators are fully equipped and protected

57079665 5 Elevator 1st Elevator Machine Room 1550 By Men’s Restroom 155

Failed Operation

Failed to shunt elevators.

Inspection & Testing Generated by: BuildingReports.com

Building: VA Sepulveda Bldg 200 The Inspection & Testing section lists all of the items inspected in your building, which are then categorized by the applicable code reference. The most recent inspection is listed in the far-right column and is based on the Finish Date of that inspection. The latest inspection uploaded in each previous quarter appears in the four columns to the left.

Passed=P, Failed=F, Replaced=R

EC 02.03.05 EP 02 Semi-annual testing of water flow devices and valve tamper switches. NFPA 72 (2022) Table 14.4.3.2 (17)(10)(a) & (17)(11)

Operate valve and verify signal receipt shall be verified to be within the first two revolutions of the hand wheel or within one-fifth of the travel distance, or per the manufacturer's published instructions. (NFPA 72-22 Table 14.4.3.2 (17)(10)(a))

Devices Annual Pass Fail Tested YTD (2024) Total Quantity Tamper Switch 19 19 0 19 19 Device Type Location ScanID Address Annual 2024 Tamper Switch 1st West Wing By 1402 Elevator Machine Room 57078936 1-03-018 Tested – 1 Turn - 02/02 - Pass Tamper Switch 1st Fire Pump Room 1113B 57079715 1-03-030B Tested – 1 Turn - 02/01 - Pass Tamper Switch 1st Fire Pump Room 1113B 57079709 1-03-030A Tested – 1 Turn - 02/01 - Pass Tamper Switch 1st Fire Pump Room 1113B 57079712 1-03-030C Tested – 1 Turn - 02/01 - Pass Tamper Switch 1st Fire Pump Room 1113B 57079708 1-03-030F Tested – 1 Turn - 02/01 - Pass Tamper Switch 1st Corridor Fire Sprinkler Hatch By Triage 1833 57079688 1-04-014 Tested – 1 Turn - 02/01 - Pass Tamper Switch 1st Fire Pump Room 1113B 57079710 1-03-032 Tested – 2 Turns - 02/01 - Pass Tamper Switch 1st Fire Pump Room 1113B (N/C) 57079707 1-03-030G Switch Tested - Pass Tamper Switch 1st Fire Pump Room 1113B (N/C) 57079713 1-03-030E Switch Tested - Pass Tamper Switch 1st Fire Pump Room 1113B (N/C) 57079714 1-03-030D Switch Tested - Pass Tamper Switch 2nd OS&Y Wing Outside Near Main Electrical Room 57079206 1-02-008 Tested – 2 Turns - 02/02 - Pass Tamper Switch 2nd West Wing Green Place Clinic Corridor By Room 23 57079202 1-02-010 Tested – 1 Turn - 02/02 - Pass Tamper Switch 2nd OS&Y Wing Outside Near Main Electrical Room 57079207 1-02-008 Tested – 1 Turn - 02/02 - Pass Tamper Switch 2nd PIV Wing Outside Near Main Electrical Room 57079208 1-02-007 Tested – 1 Turn - 02/01 - Pass Tamper Switch 2nd West Wing Patient Centered Care Stair 5 57079192 1-03-002 Tested – 1 Turn - 02/01 - Pass Tamper Switch 2nd East Wing Audiology Corridor By Room 2432

Inside 57079059 1-01-027 Tested – 1 Turn - 02/01 - Pass

Tamper Switch 3rd East Wing Corridor Cabinet By Exam 3522 57079259 1-01-014 Tested – 1 Turn - 02/01 - Pass Tamper Switch 3rd Cabinet Outside Service Elevator Lobby West Wing 57079281 1-02-016 Tested – 1 Turn - 02/01 - Pass Tamper Switch 3rd Cabinet Outside Service Elevator Lobby West Wing 57079282 1-02-018 Tested – 1 Turn - 02/01 - Pass Device Total: 19

EC 02.03.05 EP 02 Semi-annual testing of water flow devices and valve tamper switches. NFPA 72 (2022) Table 14.4.3.2 (17)(10)(a) & (17)(11)

Water shall be flowed through an inspector's test connection indicating the flow of water equal to that from a single sprinkler of the smallest orifice size installed in the system for wet-pipe systems, or an alarm test bypass connection for dry-pipe, pre-action, or deluge systems in accordance with NFPA 25-20. (NFPA 72-22 Table 14.4.3.2 (17)(11))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Waterflow Switch 9 9 0 9 9 Device Type Location ScanID Address Annual 2024 Waterflow Switch 1st West Wing By 1402 Elevator Machine Room 57078937 1-03-017 Tested – 45 Seconds - 02/02 - Pass Waterflow Switch 1st Fire Pump Room 1113B 57079711 1-03-031 Tested – 33 Seconds - 02/01 - Pass Waterflow Switch 1st Corridor Fire Sprinkler Hatch By Triage 1833 57079687 1-04-013 Tested – 40 Seconds - 02/01 - Pass Waterflow Switch 2nd West Wing Patient Centered Care Stair 5 57079193 1-03-001 Tested – 45 Seconds - 02/01 - Pass Waterflow Switch 2nd East Wing Audiology Corridor By Room 2432

Inside 57079062 1-01-026 Tested – 30 Seconds - 02/01 - Pass

Waterflow Switch 2nd West Wing Green Place Clinic Corridor By Room

57079201 1-02-009 Tested – 55 Seconds - 02/01 - Pass

Waterflow Switch 3rd East Wing Corridor Cabinet By Exam 3522 57079258 1-01-013 Tested – 40 Seconds - 02/01 - Pass Waterflow Switch 3rd Cabinet Outside Service Elevator Lobby West

Wing 57079280 1-02-015 Tested – 35 Seconds - 02/01 - Pass

Waterflow Switch 3rd Cabinet Outside Service Elevator Lobby West Wing

57079279 1-02-017 Tested – 20 Seconds - 02/01 - Pass

Device Total: 9

EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors. NFPA 72 (2022) Table 14.4.3.2 (17)

Test duct smoke detectors that use sampling tubes to ensure that they will properly sample the airstream in the duct using a method acceptable to the manufacturer or in accordance with their published instructions. (NFPA 72-22 Table 14.4.3.2 (17)(7)(e))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Duct Detector 27 27 0 27 27 Device Type Location ScanID Address Annual 2024 Duct Detector 1st Pharmacy IV Storage & Processing 1203B AHU-14 57078910 1-03-055 02/01-P Duct Detector 1st Pharmacy IV Storage & Processing 1203B AHU-10 57078911 1-03-056 02/01-P Duct Detector 2nd East Wing Blue Place Clinic Exam Room 2611 57079057 1-01-045 02/01-P Duct Detector 3rd West Wing AHU 7 Outpatient Surgery Reception Desk 57079222 1-02-048 02/01-P Duct Detector 3rd AHU 7 Corridor Outside Exam Room 3116 57079273 1-02-046 02/01-P Duct Detector 3rd AHU 7 Corridor Outside Exam Room 3130 57079274 1-02-005 02/01-P Duct Detector 3rd AHU 12 Men’s Restroom 3103 57079245 1-02-049 02/01-P Duct Detector 3rd East Wing AHU 6 Ventilation Testing Room 3535A 57079233 1-01-051 02/01-P Duct Detector 3rd East Wing AHU 5 Medical Clinic Entrance Right 57079235 1-01-053 02/01-P Duct Detector 3rd East Wing AHU 5 Medical Clinic Reception Desk 57079236 1-01-060 02/01-P Duct Detector 3rd East Wing AHU 15 Women’s Restroom 3460 By

Women’ 57079237 1-01-057 02/01-P

Duct Detector 3rd East Wing AHU 5 Room 3502 57079240 1-01-059 02/01-P Duct Detector 3rd East Wing AHU 5 Room 3502 57079241 1-01-058 02/01-P Duct Detector 3rd AHU 9 Corridor Outside 3128 HAC Room 57079275 1-02-037 02/01-P Duct Detector 3rd East Wing AHU 6 Ventilation Testing Room 3535 57079234 1-01-052 02/01-P Duct Detector 3rd East Wing Medical Clinic Room 3540A Inside Room 57079565 1-01-035 02/01-P Duct Detector 3rd East Wing AHU 3 Diagnostic Room 3540 57079239 1-01-050 02/01-P Duct Detector 3rd East Wing AHU 6 Corridor Outside ECG 3531 Behind 57079232 1-01-054 02/01-P Duct Detector 3rd East Wing Corridor AHU 1 Outside Room 3504 57079248 1-01-056 02/01-P Duct Detector 3rd East Wing Corridor AHU 1 Outside Room 3505 57079249 1-01-055 02/01-P Duct Detector 3rd West Wing AHU 7 Office 3132 57078906 1-02-044 02/01-P Duct Detector 3rd West Wing AHU 9 Surgery Vestibule Corridor Outside 57079224 1-02-042 02/01-P Duct Detector 3rd West Wing AHU 13 Surgery Vestibule Corridor Outs 57079223 1-02-043 02/01-P Duct Detector 3rd AHU 8 Corridor Outside Men’s Restroom 3103 57079246 1-02-039 02/01-P Duct Detector 3rd AHU 11 Corridor Outside Procto/Sigmoid 3105 57079243 1-02-041 02/01-P Duct Detector 3rd AHU 11 Corridor Outside Women’s Restroom 3104 57079244 1-02-040 02/01-P Duct Detector 3rd AHU 12 3100 Surgical Urology Entrance Corridor B 57079247 1-02-038 02/01-P Device Total: 27

. 9

EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors. NFPA 72 (2022) Table 14.4.3.2 (17)

Restorable: Perform heat test with a listed and labeled heat source or in accordance with the manufacturer's published instructions.

Non-Restorable: Do not perform heat test. Test functionality mechanically and electrically. (NFPA 72-22 Table 14.4.3.2 (17)(4)(a))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Heat Detector 4 4 0 4 4 Device Type Location ScanID Address Annual 2024 Heat Detector 1st West Wing 1402 Elevator Machine Room 57078935 1-03-028 02/05-P Heat Detector 1st West Wing 1302 Elevator Machine Room 57078934 1-03-029 02/05-P Heat Detector 1st West Wing Electrical Room 1359 Inside Loading Door 57078924 1-03-040 02/02-P Heat Detector 1st West Wing Switch Gear Room 1358 Inside Loading Door 57078923 1-03-039 02/02-P Device Total: 4

EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors. NFPA 72 (2022) Table 14.4.3.2 (17)

Operate manual fire alarm boxes per the manufacturer's published instructions. Test both key-operated presignal and general alarm manual fire alarm boxes. (NFPA 72-19 Table 14.4.3.2 (17)(5))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Pull Station 51 51 0 51 51 Device Type Location ScanID Address Annual 2024 Pull Station 1st Main Entrance East Wing Vestibule At Stair 6 57079035 1-04-026 02/01-P Pull Station 1st West Wing Physical Medicine Therapy Room 1104 57079033 1-03-046 02/01-P Pull Station 1st West Wing Medical Records 1405 Near Office 1404B 57078940 1-03-041 02/01-P Pull Station 1st West Wing Loading Dock Service Room 1357 57078925 1-03-042 02/01-P Pull Station 1st Bldg 200 Tunnel Entrance 57079704 1-03-047 02/01-P Pull Station 1st Corridor Exit At 1834 57079693 1-04-010 02/01-P Pull Station 1st Main Entrance West Wing Vestibule Stair 5 57079041 1-03-052 02/01-P Pull Station 1st Nurse Station Corridor By Isolation/Monitored Be 57079691 1-04-005 02/01-P Pull Station 1st C&P Department/Infusion Clinic 57079685 1-04-020 02/01-P Pull Station 1st Corridor Exit Outside Employee Health 1800 East 57079088 1-04-008 02/01-P Pull Station 1st Radiology By Elevator Machine Room 1622 At Stair 57078974 1-04-011 02/01-P Pull Station 1st Radiology Corridor By 1613 Dressing Room D 57078980 1-04-021 02/01-P Pull Station 1st West Wing Corridor By 1405 Medical Records MAS 57078951 1-03-048 02/01-P Pull Station 1st Radiology Corridor At Stair 2 By Room 1526 57078959 1-03-049 02/01-P Pull Station 1st Radiology Corridor At Stair 3 By Room 1532 57078979 1-04-023 02/01-P Pull Station 1st Radiology Corridor By 1654 Restroom 57078968 1-04-022 02/01-P Pull Station 1st Radiology Corridor By 1602 Conference Room 57078984 1-04-024 02/01-P Pull Station 1st Corridor Outside Physical Medicine 1100 57079099 1-03-051 02/01-P Pull Station 1st Corridor Outside HAC 1120 By Occupational Therapy 57079097 1-03-045 02/01-P Pull Station 1st West Wing Corridor By Men’s Restroom 1551 57078956 1-03-050 02/01-P Pull Station 1st Main Entrance West Wing 57079101 1-03-025 02/01-P Pull Station 1st West Wing Service Elevator Lobby 57078929 1-03-019 02/01-P Pull Station 1st West Wing Loading Dock By 1357 57078931 1-03-043 02/01-P Pull Station 1st West Wing Loading Dock Entrance 57078932 1-03-035 02/01-P Pull Station 1st West Wing Physical Medicine Therapy Pool 1113 57079028 1-03-044 02/01-P Pull Station 1st Main Lobby Entrance Atrium FACU 57079295 1-04-025 02/01-P Pull Station 2nd West Wing Roof Generator Room 57079203 1-02-028 02/01-P Pull Station 2nd West Wing Patient Centered Care Corridor By 2120 57079196 1-02-011 02/01-P Pull Station 2nd West Wing Patient Centered Stair 5 57079194 1-03-059 02/01-P Pull Station 2nd East Wing Audiology Reception Area 57079086 1-01-037 02/01-P Pull Station 2nd East Wing Audiology Corridor By Nurse Station 24 57079076 1-01-024 02/01-P Pull Station 2nd East Wing Blue Place Clinic Corridor At Stair 6 57079051 1-01-038 02/01-P Pull Station 2nd East Wing Audiology Service Elevator Lobby Stair 57079064 1-01-030 02/01-P Pull Station 2nd East Wing Audiology Stair 3 By Electrical Room 2 57079071 1-01-036 02/01-P Pull Station 2nd West Wing Green Place Clinic Service Elevator Lo 57079213 1-02-034 02/01-P Pull Station 2nd West Wing Green Place Clinic Corridor By Room 23 57079200 1-02-035 02/01-P Pull Station 2nd East Wing Nurse Station By 2657 57079733 1-01-025 02/01-P Pull Station 2nd West Wing Green Place Clinic Corridor By Room 23 57079214 1-02-033 02/01-P Pull Station 2nd West Wing Green Place Clinic Reception Area 57079215 1-02-006 02/01-P Pull Station 3rd East Wing Stair 6 By Biomed Storage 3561 57079257 1-01-042 02/01-P Pull Station 3rd Stair 2 57079293 1-02-054 02/01-P Pull Station 3rd East Wing Nurse Station By 3515 57079250 1-01-001 02/01-P Pull Station 3rd East Wing Stair 7 By Office 3520 57079262 1-01-040 02/01-P Pull Station 3rd East Wing Stair 3 By Electrical Room 3405 57079264 1-01-041 02/01-P Pull Station 3rd Elevator Lobby 57079291 1-02-013 02/01-P Pull Station 3rd Stair 5 By Office 3141 57079272 1-02-055 02/01-P Pull Station 3rd 3100 Surgical Urology Nurse Station 57079276 1-02-014 02/01-P Pull Station 3rd Outside West Wing Surgical Recovery Patient Room 57079286 1-02-019 02/01-P

Pull Station 3rd Stair 1 West Wing By Service Elevator Lobby 57079285 1-02-052 02/01-P Pull Station Roof West Wing 57079266 1-02-056 02/01-P Pull Station Roof East Wing 57079242 1-01-044 02/01-P Device Total: 51

EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors. NFPA 72 (2022) Table 14.4.3.2 (17)

Test smoke detectors in place to ensure smoke entry into the sensing chamber and an alarm response. (NFPA 72-22 Table 14.4.3.2 (17)(7)(a))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Smoke Detector 58 58 0 58 58 Device Type Location ScanID Address Annual 2024 Smoke Detector 1st Radiology Service Elevator Lobby By 1621 Water E 57078975 1-04-004 02/02-P Smoke Detector 1st Elevator Lobby 57078990 1-03-016 02/02-P Smoke Detector 1st Main Entrance West Wing Vestibule Electrical Roo 57079036 1-03-060 02/01-P Smoke Detector 1st Radiology Electrical Room 1526 57078958 1-03-058 02/01-P Smoke Detector 1st West Wing Corridor By 1405 Medical Records MAS C 57078950 1-03-021 02/01-P Smoke Detector 1st West Wing Connecting Tunnel Fire Doors 57078949 1-03-022 02/01-P Smoke Detector 1st West Wing Service Elevator Lobby 57078928 1-03-013 02/01-P Smoke Detector 1st West Wing Loading Dock Service Room 1357 By Room 57078921 1-03-036 02/01-P Smoke Detector 1st West Wing Loading Dock Service Room 1357 Near Bl 57078920 1-03-037 02/01-P Smoke Detector 1st West Wing Loading Dock Service Room 1357 Near Ro 57078919 1-03-038 02/01-P Smoke Detector 1st West Wing Roll Down Door Release Of Information 57078914 1-03-007 02/01-P Smoke Detector 1st Roll Down Door Laboratory 1900 Entrance 57079672 1-01-017 02/01-P Smoke Detector 1st Main Lobby Entrance Atrium FACU 57079294 1-01-016 02/01-P Smoke Detector 1st Corridor Outside Infusion & Injection Clinic Sta 57079698 1-04-006 02/01-P Smoke Detector 1st Employee Health 1800 Waiting Area 57079699 1-04-009 02/01-P Smoke Detector 1st West Wing Roll Down Door Release Of Information 57078913 1-03-008 02/01-P Smoke Detector 1st Radiology Telecom Room 1532 49519210 1-4-050 02/01-P Smoke Detector 1st Radiology Telecom Room 1525 49519209 1-03-014 02/01-P Smoke Detector 1st Telecom Room 1356 Inside Room 1357 By Loading Do 49519208 1-3-033 02/01-P Smoke Detector 1st Main Entrance West Wing Vestibule Telecom Room 1 49519207 1-3-006 02/01-P Smoke Detector 1st Clinical Lab Telecom Room 49519206 1-1-22 02/01-P Smoke Detector 1st Radiology Electrical Room 1532 57078964 1-1-012 02/01-P Smoke Detector 2nd Elevator Lobby 57079218 1-02-004 02/02-P Smoke Detector 2nd Elevator Lobby 57079217 1-02-003 02/02-P Smoke Detector 2nd West Wing Roof Generator Room 57079204 1-02-029 02/01-P Smoke Detector 2nd West Wing Roof Generator Room 57079205 1-02-030 02/01-P Smoke Detector 2nd West Wing Patient Centered Care Electrical Room 57079195 1-03-057 02/01-P Smoke Detector 2nd West Wing Roll Down Door Kitchen 2203 By Confere 57079197 1-02-057 02/01-P Smoke Detector 2nd East Wing Blue Place Clinic Electrical Room 2666 57079055 1-01-049 02/01-P Smoke Detector 2nd East Wing Audiology Service Elevator Lobby 57079066 1-01-031 02/01-P Smoke Detector 2nd East Wing Audiology Electrical Room 2465 57079070 1-01-048 02/01-P Smoke Detector 2nd West Wing Roof Main Electrical Room 57079209 1-02-032 02/01-P Smoke Detector 2nd West Wing Roof Main Electrical Room 57079210 1-02-031 02/01-P Smoke Detector 2nd West Wing Green Place Clinic Service Elevator Lobby 57079212 1-02-012 02/01-P Smoke Detector 2nd East Wing Audiology Nurse Station 2420 57079047 1-01-023 02/01-P Smoke Detector 2nd West Wing Telecom Room 2165 49519215 1-3-005 02/01-P Smoke Detector 2nd East Wing Blue Telecom Room 2664 49519214 1-1-021 02/01-P Smoke Detector 2nd East Wing Telecom Room 2466 49519213 1 02/01-P Smoke Detector 2nd West Wing Telecom Room 2366 49519211 1 02/01-P Smoke Detector 2nd West Wing Green Place Clinic Electrical Room 2365 57079199 1-02-058 02/01-P Smoke Detector 3rd East Wing Service Elevator Lobby By Office 3521 57079261 1-01-039 02/02-P Smoke Detector 3rd Service Elevator Lobby 57079284 1-02-053 02/02-P Smoke Detector 3rd Elevator Lobby 57079288 1-02-024 02/02-P Smoke Detector 3rd Elevator Lobby 57079290 1-02-020 02/02-P Smoke Detector 3rd East Wing Electrical Room 3405 By Stair 3 57079263 1-01-047 02/01-P Smoke Detector 3rd Corridor Outside Office 3138/3139 57079278 1-02-036 02/01-P Smoke Detector 3rd West Wing Electrical Room 3145 By 3143 57079271 1-02-060 02/01-P Smoke Detector 3rd West Wing Stair 5 Roll Down Door Top of Stair 57079267 1-02-001 02/01-P

Smoke Detector 3rd East Wing Stair 6 Roll Down Door By Biomed Stora 57079256 1-01-020 02/01-P Smoke Detector 3rd East Wing Electrical Room 3574 By Telephone Room 57079254 1-01-046 02/01-P Smoke Detector 3rd West Wing Telecom 3143 49519219 1-3-004 02/01-P Smoke Detector 3rd East Wing Telecom 3573 49519218 1-1-010 02/01-P Smoke Detector 3rd East Wing Stair Telecom Room 3406 49519217 1-1-011 02/01-P Smoke Detector 3rd Telecom Room 3326 49519216 1-3-003 02/01-P Smoke Detector 3rd West Wing Electrical Room 3327 By Stair 2 57079292 1-02-059 02/01-P Smoke Detector 3rd East Wing Nurse Station By 3515 57079238 1-01-002 02/01-P Smoke Detector 3rd 3100 Surgical Urology Left Entrance Corridor 57079277 1-02-051 02/01-P Smoke Detector 3rd 3100 Surgical Urology Right Entrance Corridor 57079287 1-02-050 02/01-P Device Total: 58

EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door releasing devices. NFPA 72 (2022) Table 14.4.3.2 (22)

For periodic testing, verify the operation of the notification appliances. (NFPA 72-22 Table 14.4.3.2 (22)(1))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Horn/Strobe 4 4 0 4 4 Device Type Location ScanID Address Annual 2024 Horn/Strobe Roof East Wing 57079727 1 02/01-P Horn/Strobe Roof West Wing 57079728 1 02/01-P Horn/Strobe Roof West Wing 57079729 1 02/01-P Horn/Strobe Roof East Wing 57079731 1 02/01-P Device Total: 4

EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door releasing devices. NFPA 72 (2022) Table 14.4.3.2 (22)

Test interface equipment connections by operating or simulating the equipment being supervised. Verify signals required to be transmitted are received at the control unit. (NFPA 72-22 Table 14.4.3.2 (20))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Releasing Device 17 17 0 17 17 Device Type Location ScanID Address Annual 2024 Releasing Device 1st Corridor Exit Outside Employee Health 1800 East 57079087 1 02/01-P Releasing Device 1st Radiology By 1621 Water Equipment Room Fire Door 57078973 1 02/01-P Releasing Device 1st Radiology Corridor By 1620 Equipment Storage Fir 57078972 1 02/01-P Releasing Device 1st West Wing Connecting Tunnel Fire Doors 57078948 1 02/01-P Releasing Device 1st West Wing Connecting Tunnel Fire Doors 57078947 1 02/01-P Releasing Device 1st Laboratory 1900 Entrance 57079671 1 02/01-P Releasing Device 1st Hallway By Employee Health 1800 Outside Staff Re 57079684 1 02/01-P Releasing Device 1st MCCR Waiting Area 1706 57079701 1 02/01-P Releasing Device 2nd East Wing Corridor P.E.R.C Room 2500 57079046 1 02/01-P Releasing Device 2nd East Wing Corridor P.E.R.C Room 2500 57079045 1 02/01-P Releasing Device 3rd West Wing Outpatient Surgery Reception Area 57079629 1 02/01-P Releasing Device 3rd West Wing Outpatient Surgery Reception Area 57079628 1 02/01-P Releasing Device 3rd West Wing Outpatient Surgery Reception Area 57079627 1 02/01-P Releasing Device 3rd West Wing Outpatient Surgery Reception Area 57079626 1 02/01-P Releasing Device 3rd West Wing Outpatient Surgery Corridor Near 3410 57079597 1 02/01-P Releasing Device 3rd East Wing Corridor Entrance to 3440-3449 57079265 1 02/01-P Releasing Device 3rd 3100 Surgical Urology Nurse Station 57079730 1 02/01-P Device Total: 17

EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door releasing devices. NFPA 72 (2022) Table 14.4.3.2 (22)

For periodic testing, verify the operation of the notification appliances. (NFPA 72-22 Table 14.4.3.2 (22)(2))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Speaker/Strobe 142 142 0 142 142 Device Type Location ScanID Address Annual 2024 Speaker/Strobe 1st Main Entrance West Wing 57079100 1 02/01-P Speaker/Strobe 1st Main Lobby Entrance Atrium FACU 57079098 1 02/01-P Speaker/Strobe 1st Corridor Outside HAC 1120 By Occupational Therapy 57079096 1 02/01-P Speaker/Strobe 1st Corridor Outside Exam Room 1124 57079094 1 02/01-P Speaker/Strobe 1st Corridor Outside Men’s Locker Room 1106 By Physical 57079093 1 02/01-P Speaker/Strobe 1st Hallway By Employee Health 1800 57079090 1 02/01-P Speaker/Strobe 1st Corridor Exit Outside Employee Health 1800 East 57079089 1 02/01-P Speaker/Strobe 1st Main Entrance West Wing Vestibule Storage Room 1 57079040 1 02/01-P Speaker/Strobe 1st West Wing Physical Medicine Therapy Room 1104 57079032 1 02/01-P Speaker/Strobe 1st West Wing Physical Medicine Therapy Room 1104 57079031 1 02/01-P Speaker/Strobe 1st West Wing Physical Medicine Occupational Therapy 57079029 1 02/01-P Speaker/Strobe 1st West Wing Physical Medicine Therapy Pool 1113 57079027 1 02/01-P Speaker/Strobe 1st West Wing Physical Medicine Therapy Pool 1113 57079026 1 02/01-P Speaker/Strobe 1st Radiology Reception Desk By Vending Machine 57078987 1 02/01-P Speaker/Strobe 1st By Radiology Reception Desk 57078986 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1601 Imaging Film Library 57078985 1 02/01-P Speaker/Strobe 1st Radiology Corridor At 1643 HAC Room 57078983 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1605 Ultrasound Room 57078982 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1620 Equipment Storage 57078977 1 02/01-P Speaker/Strobe 1st Laboratory 1900 Entrance 57079673 1 02/01-P Speaker/Strobe 1st Clinical Lab 1928 57079677 1 02/01-P Speaker/Strobe 1st Clinical Lab 1928 By Immunology 1904 57079678 1 02/01-P Speaker/Strobe 1st Clinical Lab 1928 By Immunology 1911 57079679 1 02/01-P Speaker/Strobe 1st Clinical Lab 1928 By Office 1916 57079682 1 02/01-P Speaker/Strobe 1st Clinical Lab 1928 By 1927 Behind Ultra Low Freez 57079683 1 02/01-P Speaker/Strobe 1st C&P Department/Infusion Clinic 57079686 1 02/01-P Speaker/Strobe 1st Corridor By Monitored Bed 1 57079689 1 02/01-P Speaker/Strobe 1st Corridor By Triage 1833 57079692 1 02/01-P Speaker/Strobe 1st Corridor Exit At 1834 57079694 1 02/01-P Speaker/Strobe 1st Corridor By Exam 1802 57079695 1 02/01-P Speaker/Strobe 1st Radiology Service Elevator Lobby By 1621 Water E 57079700 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1627 Dressing Room 1 57078971 1 02/01-P Speaker/Strobe 1st Radiology MRI Zone 3 57078970 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1654 Restroom 57078967 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1531 Tech Lounge 57078963 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1527 HAC Room 57078960 1 02/01-P Speaker/Strobe 1st Radiology Corridor By 1521 Bio-Safety Lounge 57078957 1 02/01-P Speaker/Strobe 1st West Wing Corridor By 1554 Uniform Exchange 57078954 1 02/01-P Speaker/Strobe 1st West Wing Corridor By 1209 Work Area 57078953 1 02/01-P Speaker/Strobe 1st West Wing Corridor By 1404 MRT/ROI Work Area 57078952 1 02/01-P Speaker/Strobe 1st Prosthetics At Reception Desk 57078946 1 02/01-P Speaker/Strobe 1st Prosthetics Corridor By Room 1510 57078944 1 02/01-P Speaker/Strobe 1st Prosthetics Corridor By Room 1505 57078942 1 02/01-P Speaker/Strobe 1st West Wing Medical Records 1405 S/E Exit 57078941 1 02/01-P Speaker/Strobe 1st West Wing Medical Records 1405 Office Area Above 57078939 1 02/01-P Speaker/Strobe 1st West Wing Medical Records 1405 Near Office 1405A 57078938 1 02/01-P Speaker/Strobe 1st West Wing Loading Dock Entrance 57078933 1 02/01-P Speaker/Strobe 1st West Wing Loading Dock By 1357 57078930 1 02/01-P

Speaker/Strobe 1st West Wing Loading Dock Service Room 1357 57078926 1 02/01-P Speaker/Strobe 1st West Wing Loading Dock Service Room 1357 By Room 57078922 1 02/01-P Speaker/Strobe 1st West Wing Inside S.P.D Room 1301 Prep & Pack Room 57078916 1 02/01-P Speaker/Strobe 1st Pharmacy By IV Storage & Processing 1203 57078912 1 02/01-P Speaker/Strobe 1st Pharmacy Above Storage Area 57078905 1 02/01-P Speaker/Strobe 1st Radiology Open Area By Office 1637 57079702 1 02/01-P Speaker/Strobe 1st Bldg 200 Tunnel Entrance 57079703 1 02/01-P Speaker/Strobe 1st Corridor Outside Medical Records 1405 57079705 1 02/01-P Speaker/Strobe 1st West Wing Service Elevator Lobby 57079706 1 02/01-P Speaker/Strobe 2nd West Wing Green Pace Clinic Reception Area 57079630 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 230 57079633 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 232 57079636 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 232 57079634 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 231 57079635 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 233 57079642 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Women’s Locker Room 57079644 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Office 213 57079647 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Office 213 57079648 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Clean Util 57079650 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Mental Hea 57079651 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Multipurpose 57079653 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Reception Area 57079657 1 02/02-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Exam Room 57079654 1 02/02-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 237 57079637 1 02/01-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Exam Roo 57079639 1 02/01-P Speaker/Strobe 2nd West Wing Green Pace Clinic Corridor By Room 235 57079641 1 02/01-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Office 216 57079649 1 02/01-P Speaker/Strobe 2nd West Wing Telecom Room 2366 57079640 1 02/01-P Speaker/Strobe 2nd Corridor Outside Exam 2614 57079298 1 02/01-P Speaker/Strobe 2nd Corridor Outside Pharmacist 2606 57079297 1 02/01-P Speaker/Strobe 2nd Corridor Outside Soiled Utility 2655 57079227 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Reception Area 57079085 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Room 2407 57079082 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Room 2414 57079081 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Inside Audiometric Booth 57079080 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Inside Audiometric Booth EX 57079079 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Room 2422 57079078 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Storage Room 241 57079077 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Room 2456 57079074 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By MAS Room 2452 57079073 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Room 2469 57079072 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Staff Break Room 57079069 1 02/01-P Speaker/Strobe 2nd East Wing Audiology Corridor By Service Elevator 57079063 1 02/01-P Speaker/Strobe 2nd East Wing Blue Place Clinic Corridor By Nurse St 57079056 1 02/01-P Speaker/Strobe 2nd East Wing Blue Place Clinic Corridor At Stair 6 57079050 1 02/01-P Speaker/Strobe 2nd East Wing Blue Place Clinic Corridor By Room 266 57079049 1 02/01-P Speaker/Strobe 2nd East Wing Blue Place Clinic Corridor By Room 262 57079048 1 02/01-P Speaker/Strobe 2nd East Wing Blue Place Clinic Corridor By Reception 57079043 1 02/01-P Speaker/Strobe 2nd West Wing Corridor By Conference Room A 57079659 1 02/01-P Speaker/Strobe 2nd West Wing Red Pace Clinic Corridor By Pharmacist 57079655 1 02/01-P Speaker/Strobe 2nd West Wing Conference Room A 57079660 1 02/01-P Speaker/Strobe 2nd West Wing Corridor By Conference Room B 57079661 1 02/01-P Speaker/Strobe 2nd West Wing Conference Room B 57079662 1 02/01-P Speaker/Strobe 2nd Corridor Outside Offices 2634/2636 57079732 1 02/01-P Speaker/Strobe 2nd Corridor Outside Exam Room 2679 57079734 1 02/01-P

Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Room 32 57079625 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Room 32 57079622 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Room 32 57079621 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Operation 57079620 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery S/E Corridor Near R 57079619 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Staff Dressing Room 57079613 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Room 32 57079612 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Women’s 57079609 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Exam Ro 57079604 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Exam Ro 57079603 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor By Exam Ro 57079602 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor At Nurses 57079599 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor Near Recep 57079596 1 02/02-P Speaker/Strobe 3rd West Wing Eye Clinic Corridor By Office 3324 57079595 1 02/02-P Speaker/Strobe 3rd West Wing Outpatient Surgery Corridor Near 3410 57079594 1 02/02-P Speaker/Strobe 3rd West Wing Eye Clinic Corridor By Office 3316 57079592 1 02/02-P Speaker/Strobe 3rd West Wing Eye Clinic Corridor By Exam Room 3308 57079591 1 02/02-P Speaker/Strobe 3rd Elevator Lobby 57079588 1 02/02-P Speaker/Strobe 3rd West Wing Eye Clinic Waiting Area 57079589 1 02/02-P Speaker/Strobe 3rd East Wing Women’s Clinic Corridor By Sub-Waiting 57079587 1 02/02-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Office 3562 57079583 1 02/02-P Speaker/Strobe 3rd East Wing Entrance To Neurology Biomed 57079582 1 02/02-P Speaker/Strobe 3rd East Wing Near Reception Desk Medical Clinic 57079581 1 02/02-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Corridor 57079580 1 02/02-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Corridor 57079578 1 02/02-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Corridor 57079577 1 02/02-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Corridor 57079575 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Inside Room 3545 Bio Me 57079572 1 02/01-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Corridor 57079574 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor At Room 3551 57079571 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Room 3557 57079568 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic By Room 3534 57079566 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Room 3542 57079564 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Room 3511 57079562 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Room 3508 57079561 1 02/01-P Speaker/Strobe 3rd East Wing Medical Clinic Corridor By Room 3502 57079560 1 02/01-P Speaker/Strobe 3rd East Wing Women’s Clinic/Head And Neck Waiting L 57079559 1 02/01-P Speaker/Strobe 3rd West Wing Telecom 3143 57079598 1 02/01-P Speaker/Strobe 3rd East Wing Corridor Near Stair 6 At Room 3574 57079584 1 02/01-P Device Total: 142

EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door releasing devices. NFPA 72 (2022) Table 14.4.3.2 (22)

For periodic testing, verify that each appliance flashes. (NFPA 72-22 Table 14.4.3.2 (22)(3))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Strobe 67 67 0 67 67 Device Type Location ScanID Address Annual 2024 Strobe 1st Corridor Outside Therapy Pool 1113 57079095 1 02/02-P Strobe 1st Men’s Locker Room 1106 By Physical Therapy 57079092 1 02/02-P Strobe 1st Women’s Locker Room 1105 By Physical Therapy 110 57079091 1 02/02-P Strobe 1st West Wing Physical Medicine Kinesiotherapy Room 57079034 1 02/02-P Strobe 1st West Wing Physical Medicine Occupational Therapy 57079030 1 02/02-P Strobe 1st Women’s Restroom 1711 57078988 1 02/02-P Strobe 1st Radiology Restroom 1612 57078981 1 02/02-P Strobe 1st Radiology Restroom 1617 57078978 1 02/02-P Strobe 1st Laboratory 1900 Restroom 1903 57079675 1 02/01-P Strobe 1st Laboratory 1900 Restroom 1902 57079676 1 02/01-P Strobe 1st Clinical Lab 1928 Staff Restroom 1914 57079680 1 02/01-P Strobe 1st Clinical Lab 1928 Staff Restroom 1915 57079681 1 02/01-P Strobe 1st Restroom 1823 57079690 1 02/01-P Strobe 1st Restroom 1805 57079696 1 02/01-P Strobe 1st Infusion & Injection Clinic Staff Restroom 1810 57079697 1 02/01-P Strobe 1st Radiology Restroom 1632 Inside Room 1633 57078969 1 02/01-P Strobe 1st Radiology Corridor Restroom 1654 57078966 1 02/01-P Strobe 1st Radiology Corridor Restroom 1652 57078965 1 02/01-P Strobe 1st Radiology Women’s Locker Room 1530 57078962 1 02/01-P Strobe 1st Radiology Men’s Locker Room 1529 57078961 1 02/01-P Strobe 1st West Wing Men’s Restroom 1551 57078955 1 02/01-P Strobe 1st Prosthetics Restroom 1506 57078945 1 02/01-P Strobe 1st Prosthetics Staff Restroom 1513 57078943 1 02/01-P Strobe 1st West Wing Women’s Locker Room 1303 57078918 1 02/01-P Strobe 1st West Wing Men’s Restroom 1304 57078917 1 02/01-P Strobe 1st Pharmacy Inside 1206 Pharmacy Reception 57078909 1 02/01-P Strobe 1st Pharmacy Staff Restroom 1205 57078907 1 02/01-P Strobe 2nd East Wing Audiology Reception Area Women’s Restroom 57079084 1 02/02-P Strobe 2nd East Wing Audiology Reception Area Men’s Restroom 57079083 1 02/02-P Strobe 2nd East Wing Audiology Restroom 2486 57079075 1 02/02-P Strobe 2nd East Wing Audiology Men’s Locker Room 2430 57079067 1 02/02-P Strobe 2nd East Wing Audiology Women’s Locker Room 2435 57079068 1 02/02-P Strobe 2nd East Wing Audiology Women’s Locker 2431 57079061 1 02/02-P Strobe 2nd East Wing Blue Place Clinic Locker Room 2630 57079060 1 02/02-P Strobe 2nd East Wing Blue Place Clinic Restroom 2685 57079058 1 02/02-P Strobe 2nd East Wing Blue Place Clinic Reception Desk Women 57079044 1 02/02-P Strobe 2nd East Wing Blue Place Clinic Reception Desk Men’s 57079042 1 02/02-P Strobe 2nd West Wing Green Pace Clinic Reception Area Men’s 57079631 1 02/02-P Strobe 2nd West Wing Green Pace Clinic Reception Area Women’s

Restroom 2303 57079632 1 02/02-P

Strobe 2nd West Wing Green Pace Clinic Restroom 2386 57079638 1 02/02-P Strobe 2nd West Wing Green Pace Clinic Women’s Locker Room 57079645 1 02/02-P Strobe 2nd West Wing Green Pace Clinic Men’s Locker Room 23 57079643 1 02/02-P Strobe 2nd West Wing Red Pace Clinic Men’s Locker Room 2130 57079646 1 02/02-P Strobe 2nd West Wing Green Pace Clinic Women’s Locker Room 57079652 1 02/02-P Strobe 2nd West Wing Red Pace Clinic Women’s Restroom 2150 57079656 1 02/01-P Strobe 2nd West Wing Red Pace Clinic Reception Area Men’s

Restroom 57079658 1 02/01-P

Strobe 3rd West Wing Outpatient Surgery Women’s Locker Room 57079610 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Men’s Locker Room 3 57079608 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Restroom 3101 57079607 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Corridor By Restroom 57079606 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Inside Exam Room 31 57079605 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Utility Closet 3111 57079601 1 02/02-P Strobe 3rd West Wing Outpatient Surgery 3114 Restroom 57079600 1 02/02-P Strobe 3rd West Wing Eye Clinic Restroom 3304 Reception Are 57079590 1 02/02-P Strobe 3rd West Wing Eye Clinic Restroom 3321 57079593 1 02/02-P Strobe 3rd East Wing Women’s Clinic Women’s Restroom 3460 57079585 1 02/02-P Strobe 3rd East Wing Women’s Clinic/Head And Neck Women’s L 57079579 1 02/02-P Strobe 3rd East Wing Women’s Clinic/Head And Neck Men’s Loc 57079576 1 02/02-P Strobe 3rd East Wing Medical Clinic Inside Lounge 3556 57079570 1 02/02-P Strobe 3rd East Wing Medical Clinic Inside Room 3557 57079569 1 02/02-P Strobe 3rd East Wing Medical Clinic Restroom Inside Room 35 57079567 1 02/02-P Strobe 3rd East Wing Medical Clinic Restroom 3514 57079563 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Room 3206 Recovery 57079611 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Women’s Locker Room 57079614 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Men’s Locker Room 3 57079616 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Staff Restroom 3203 57079624 1 02/02-P Strobe 3rd West Wing Outpatient Surgery Men’s Locker Room 3 57079617 1 02/02-P Device Total: 67

. 21

EC 02.03.05 EP 05 Annual test of fire alarm equipment for notifying off-site fire responders. NFPA 72 (2022) Table 14.4.3.2 (4)

Test all system functions and features in accordance with the equipment manufacturer's published instructions for correct operation in conformance with the applicable sections of Chapter 26. Except for DACT, actuate initiating device and verify receipt of the correct initiating device signal at the supervising station within 90 seconds. Upon completion of the test, restore the system to its functional operating condition. (NFPA 72-22 Table 14.4.3.2 (4))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Communicator 1 1 0 1 1 Device Type Location ScanID Address Annual 2024 Communicator 1st Blood Lab 1900 Room 1926 57079722 1 02/01-P Device Total: 1

EC 02.03.05 EP 11 For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow. Fire pump supervisory signals for pump running and pump power loss are tested annually. NFPA 25 (2023) 8.3.3

Verify correct receipt of alarm, supervisory and trouble signals (inputs), operation of evacuation signals and auxiliary functions (outputs), circuit supervision including detection of open circuits and ground faults, and power supply supervision for detection of loss of ac power and disconnection of secondary batteries. (NFPA 72-22 Table 14.4.3.2 (2)(1))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Fire Pump Trouble 1 1 0 1 1 Device Type Location ScanID Address Annual 2024 Fire Pump Trouble 1st Fire Pump Room 1113B 57079716 1 02/01-P

EC 02.03.05 EP 19 Annual test of automatic smoke-detection shutdown devices for air-handling equipment. NFPA 90A (2024) 6.4.1

Test duct smoke detectors that use sampling tubes to ensure that they will properly sample the airstream in the duct using a method acceptable to the manufacturer or in accordance with their published instructions. (NFPA 72-22 Table 14.4.3.2 (17)(7)(e))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Duct Detector 27 27 0 27 27 Device Type Location ScanID Address Annual 2024 Duct Detector 1st Pharmacy IV Storage & Processing 1203B AHU-14 57078910 1-03-055 02/01-P Duct Detector 1st Pharmacy IV Storage & Processing 1203B AHU-10 57078911 1-03-056 02/01-P Duct Detector 2nd East Wing Blue Place Clinic Exam Room 2611 57079057 1-01-045 02/01-P Duct Detector 3rd West Wing AHU 7 Outpatient Surgery Reception Desk 57079222 1-02-048 02/01-P Duct Detector 3rd AHU 7 Corridor Outside Exam Room 3116 57079273 1-02-046 02/01-P Duct Detector 3rd AHU 7 Corridor Outside Exam Room 3130 57079274 1-02-005 02/01-P Duct Detector 3rd AHU 12 Men’s Restroom 3103 57079245 1-02-049 02/01-P Duct Detector 3rd East Wing AHU 6 Ventilation Testing Room 3535A 57079233 1-01-051 02/01-P Duct Detector 3rd East Wing AHU 5 Medical Clinic Entrance Right 57079235 1-01-053 02/01-P Duct Detector 3rd East Wing AHU 5 Medical Clinic Reception Desk 57079236 1-01-060 02/01-P Duct Detector 3rd East Wing AHU 15 Women’s Restroom 3460 By Women’ 57079237 1-01-057 02/01-P Duct Detector 3rd East Wing AHU 5 Room 3502 57079240 1-01-059 02/01-P Duct Detector 3rd East Wing AHU 5 Room 3502 57079241 1-01-058 02/01-P Duct Detector 3rd AHU 9 Corridor Outside 3128 HAC Room 57079275 1-02-037 02/01-P Duct Detector 3rd East Wing AHU 6 Ventilation Testing Room 3535 57079234 1-01-052 02/01-P Duct Detector 3rd East Wing Medical Clinic Room 3540A Inside Room 57079565 1-01-035 02/01-P Duct Detector 3rd East Wing AHU 3 Diagnostic Room 3540 57079239 1-01-050 02/01-P Duct Detector 3rd East Wing AHU 6 Corridor Outside ECG 3531 Behind 57079232 1-01-054 02/01-P Duct Detector 3rd East Wing Corridor AHU 1 Outside Room 3504 57079248 1-01-056 02/01-P Duct Detector 3rd East Wing Corridor AHU 1 Outside Room 3505 57079249 1-01-055 02/01-P Duct Detector 3rd West Wing AHU 7 Office 3132 57078906 1-02-044 02/01-P Duct Detector 3rd West Wing AHU 9 Surgery Vestibule Corridor Outside 57079224 1-02-042 02/01-P Duct Detector 3rd West Wing AHU 13 Surgery Vestibule Corridor Outs 57079223 1-02-043 02/01-P Duct Detector 3rd AHU 8 Corridor Outside Men’s Restroom 3103 57079246 1-02-039 02/01-P Duct Detector 3rd AHU 11 Corridor Outside Procto/Sigmoid 3105 57079243 1-02-041 02/01-P Duct Detector 3rd AHU 11 Corridor Outside Women’s Restroom 3104 57079244 1-02-040 02/01-P Duct Detector 3rd AHU 12 3100 Surgical Urology Entrance Corridor B 57079247 1-02-038 02/01-P Device Total: 27

EC 02.03.05 EP 20 Annual operation and full closure of sliding and rolling fire and smoke barrier doors for proper operation and full closure. NFPA 80-2022 5.2.4.1; NFPA 105-2022 5.2.1; 5.2.2

Test interface equipment connections by operating or simulating the equipment being supervised. Verify signals required to be transmitted are received at the control unit. (NFPA 72-22 Table 14.4.3.2 (20))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Roll Down Door 4 4 0 4 5 Device Type Location ScanID Address Annual 2024 Roll Down Door 1st West Wing Release Of Information Waiting Lobby 1 57078915 1 02/01-P Roll Down Door 1st Laboratory 1900 Entrance 57079674 1 Not In Service Roll Down Door 2nd West Wing Kitchen 2203 By Conference Room C 57079198 1 02/01-P Roll Down Door 3rd East Wing Stair 6 Roll Down Door Top of Stair By 57079255 1 02/01-P Roll Down Door 3rd West Wing Stair 5 Roll Down Door Top of Stair 11223344 1 02/01-P Device Total: 5

LS 02.01.34 EP 02 Protected master fire alarm control panel

Verify correct receipt of alarm, supervisory and trouble signals (inputs), operation of evacuation signals and auxiliary functions (outputs), circuit supervision including detection of open circuits and ground faults, and power supply supervision for detection of loss of ac power and disconnection of secondary batteries. (NFPA 72-22 Table 14.4.3.2 (2)(1))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Control Panel 1 1 0 1 1 Device Type Location ScanID Address Annual 2024 Control Panel 1st Main Lobby Entrance Atrium 57079299 1 02/01-P

LS 02.01.34 EP 10 All other Life Safety Code fire alarm requirements related to NFPA 101-2024 18/19.3.4

With the batteries fully charged and connected to the charger, measure the voltage across the batteries with a voltmeter. Then, with the battery charger disconnected, load test the batteries following the manufacturer's recommendations. (NFPA 72-22 Table 14.4.3.2 (9))

Devices Annual 2024 Pass Fail Tested YTD (2024) Total Quantity Battery 14 14 0 14 14 Device Type Location ScanID Address Annual 2024 Battery 1st Blood Lab 1900 Room 1926 BPS 57079724 1 02/01-P Battery 1st Blood Lab 1900 Room 1926 BPS 57079725 1 02/01-P Battery 1st Main Entrance West Wing Vestibule Electrical Roo 57079038 1 02/01-P Battery…