LLVA Master report 2022 (003).pdf

VA LOMA LINDA HOSPITAL

Fire Door Assemblies

Inspection Report

Prepared by:

VA Loma Linda Hospital

Fire Door Assemblies Inspection Report

Submitted: 12/1/2022

Report Contents:

Section I Summary Report

Section II Applicable Code

Section III Report Legend

Section IV Fire Door Inventory

Section V Discrepancy Count by Type

Section VI Discrepancy Count by Assembly ID#

Section VII ILSM/Plan of Correction

Section I Summary Report

Section II Applicable Code

NFPA 80 2010 - Inspection Code Reference #:

[Bolded] Minimum Performed; NI= Not Necessarily Inspected or Required; [Grey colored text is reference material]

5.2 Inspections: 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed for inspection by the a AHJ

N/A N/A - 5.2.2 Performance-Based Option: 5.2.2.3 Technical justification for inspection, testing, and maintenance intervals shall be documented.

5.2.3 Functional Testing: 5.2.3.1 Functional testing fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

1a 5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware: 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 5.2.4.2 as a minimum, the following items shall be verified:

1 5.2.4.2(1) No open holes or breaks exist in surfaces of either the door or frame 2 5.2.4.2(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped 3 5.2.4.2(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage 4 5.2.4.2(4) No parts are missing or broken 5 5.2.4.2(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.

5a 4.8.4 Clearance. 4.8.4.1 The clearance under the bottom of a door shall be a maximum of 3/4 in.

5b 6.3.1.7 Clearances: 6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, the meeting edges of doors swinging in pairs, shall be 1/8 in. ± 1/16 in. for steel doors and shall not exceed 1/8 in.

for wood doors. 6.3.1.7.2 Clearances shall be measured from the pull face of the door(s).

NFPA 101 2012 §19.3.6.3.4 A clearance between the bottom of the door in the floor covering not exceeding 1” inch shall be permitted for corridor doors [sprinkled area].

6 5.2.4.2(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position

7 5.2.4.2(7) If a coordinator is installed, the inactive leaf closes before the active leaf 8 5.2.4.2(8) Latching hardware operates and secures the door when it is in the closed position 9 5.2.4.2(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame 10 5.2.4.2(10) No field modifications to the door assembly have been performed that void the label 11 5.2.4.2(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity 12 6.4.5 Protection Plates: 6.4.5.1 Factory-installed protection plates shall be installed in accordance with the listing of the door. 6.4.5.2 Field-installed protection plates [>16”] shall be labeled and installed in accordance with their listing. 6.4.5.3 Labeling shall not be required where the top of the protection plate is not more than 16 in. above the bottom of the door.

13a 6.4.4 Locks or Latches: 6.4.4.1 Only labeled locks and latches or labeled fire exit hardware (panic devices) meeting both life safety requirements and fire protection requirements shall be used. 6.4.4.2 Fire exit hardware shall be installed only on fire doors bearing a label stating "Fire Door to be Equipped with Fire Exit Hardware".

13b 6.4.4.2.2 Fire exit hardware shall have a permanently attached label that bears the serial number and shows the manufacturer's name and type of approval

14 5.2.13 Prevention of Door Blockage: 5.2.13.1 door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door. 5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited

15a 4.1.4 Signage: 4.1.4.1 The total area of all attached signs shall not exceed 5 percent of the area of the face of the fire door to which they are attached.

15b 4.1.4.2 Signs shall be attached to fire doors by use of an adhesive/Mechanical attachments such as screws or nails shall not be permitted

15c 4.1.4.3 Signs shall not be installed on glazing material in fire doors 16 4.3.1 Classification and Types of Doors. 4.3.1 Only labeled fire doors shall be used NI 5.2.5 Horizontally Sliding, Vertically Sliding, and Rolling Doors (Normally done by others) NI 5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions (Normally done by fire alarm testing company).

NI 5.2.7 Assembly shall be reset after a successful test.

The Joint Commission

EC.02.03.05

EP 25

Testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.

Clarification letter - May

24, 2017

TJC does not require inspecting/testing corridor doors (i.e., patient room doors), or Office doors (provided the room does not contain flammable or combustible materials) to be included in the annual door inspection.

(See other AHJs (CMS, CDPH, Insurance, Bonds, etc.) before making this decision)

NFPA 101 2012 (Life Safety Code) NI 7.2.1.5.10.1 The releasing mechanism for any latch shall be located as follows: (1) Not less than 34 inches above the finished floor for other than existing installations. (2) Not more than 48 inches above the finished floor.

NI 7.2.1.5.11 where pairs of door leaves are required in a means of egress, one of the following criteria shall be met:

(1) Each leaf of the pairs shall be provided with the releasing device that does not depend on the release of one leaf before the other.

(2) Approved automatic flush bolts shall be used and arranged such that both of the following criteria are met:

(a) The door leaf equipped with the automatic flush bolts shall have no doorknob or surface mounted hardware.

(B) Unlatching of any leaf should not require more than one operation.

NI 19.3.6.1 Corridor separation. Corridor doors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following:

(1) smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size open to the court or, provided that all of the following criteria are met:

(a)* The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers.

(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurse station or similar space.

(d) The space does not obstruct access required exits.

A. 19.3.6.1 (1) (a) the presence of stored combustible materials in a room or space open to the corridor does not necessarily result in the room or space being classified as a hazardous area.

NI 19.3.6.2 Construction of corridor walls. 19.3.6.2.2* Corridor walls shall have a minimum ½-hour fire resistance rating.

A .19 .3 .6 .2 .2 The intent of the minimum 1/2 -hour fire resistance rating corridor door partitions is to require a nominal fire rating, particularly where the fire rating of existing partitions cannot be documented. Examples of acceptable partition assemblies would include, but are not limited to, ½” in. gypsum board, wood lath and plaster, gypsum lath or metal lath and plaster.

19.3.6.2.4* in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling with the ceiling is constructed to limit the transfer of smoke.

NI

NI

Reasoning

Per:

19.3.6.3 Corridor Doors: 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:

(1) 13⁄4 in. (44 mm) thick, solid-bonded core wood.

(2) Material that resists fire for a minimum of 20 minutes.

A.19.3.6.3.1 Gasketing of doors should not be necessary to achieve resistance to the passage of smoke if the doors relatively tight fitting.

§19.3.6.3.2 “The requirements of 19.3.6.3.1 [Corridor doors with 1/2-hour fire resistance rating, smoke resistant, latching] shall not apply where otherwise permitted by either of the following”:

(1) Doors to toilet rooms, bathrooms, shower rooms, closets, and similar auxiliary spaces that do not contain flammable combustible materials shall not be required to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction

NFPA 105 2010 Standard for [the installation] Smoke Door Assemblies and Other Opening NI Reasoning: Corridor doors that are non-rated or 20 minute corridor doors in a non-rated wall [or just smoke resistive doors] per NFPA 101 2012 healthcare occupancies, 19.3.6.3.1 are not subject to meeting NFPA 80.

And, NFPA 105, 2010 The Standard for [the installation of] Smoke Door Assemblies and Other Opening Protectives, §5.2.1.1 is not required in fully sprinkled buildings.

NI Smoke door assembly is any combination of door, frame, hardware, and any other accessories that together restrict smoke movement through door openings by limiting the amount of air that can pass through the assembly.

NI

5.2.1

Inspections.

5.2.1.1 Smoke door assemblies shall be inspected annually.

5.2.1.2 Doors shall be operated to confirm for closure.

5.2.1.3 Hardware and gaskets shall be inspected annually, and any parts found to be damaged or in operative shall be replaced.

5.2.1.4 10 Tin clad and Kalamein doors shall be inspected regularly for dry rot

5.2.1.5 A written record shall be maintained shall be made available to the authority having jurisdiction.

NI

Ch. 4

Smoke door assemblies (including fire doors that are also smoke doors) shall have an air leakage rating not greater than 3 cubic feet/minute/square foot (0.9 m3/min/m2) of door opening when tested in accordance with ANSI/UL 1784, Air Leakage Tests of Door Assemblies, and the door shall bear an “S” label indicating compliance with this requirement.

NI See CMS guidance for the air gaps around the door and frame in (S&C-07-18. DATE:

April 20, 2007) (although referencing to the 2000 Life Safety Code, it should still be applicable).

materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.3, Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, shall not be required [for fully sprinkled, corridor doors that are just smoke barrier doors].

NI 19.3.6.3.4 A clearance between the bottom of the door in the floor covering not exceeding 1” inch shall be permitted for corridor doors.

Summary of NI reasoning if fully sprinkled:

#1. Per 19.3.6.3.2 The requirements for 19.3.6.3.1 [Corridor doors with 1/2-hour fire resistance rating and latching] shall not apply.

#2. Per NFPA 101 2012 §19.3.6.3.3, [referencing fully sprinkled, corridor doors that are just smoke barrier doors], states: “Compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, shall not be required”.

# 3. NFPA 105, 2010 The Standard for [the Installation of] Smoke Door Assemblies and Other Opening Protectives should not be considered applicable just because of NFPA 101 2012 Chapter 2 referemce.

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Section III Report Legend

Purpose of Assembly

Code Purpose

1HR One Hour Fire Barrier

1-HR FR Corr 1-HR Fire Rated Corridor

1-HR Occ Sep 1-HR Occupancy Separation

1-HR Smoke 1-HR Smokestop Partition

1HR/S One Hour Fire and Smoke Barrier

1HR/Suite One Hour Fire Barrier and Suite Wall

2HR Two Hour Fire Barrier

2-HR Occ Sep 2-HR Occupancy Separation

2-HR Occ/1-HR Smoke

2HR/S Two Hour Fire and Smoke Barrier

2HR/S/HRZ. Exit Two Hour Fire and Smoke Barrier and Horizontal Exit

3HR Three Hour Fire Barrier

3HR/S Three Hour Fire and Smoke Barrier

4-HR Wall

Corr/1-HR Occ

Corr/1-HR Smoke

Corr/1-HR Smoke/1-HR Occ

Corr/2-HR Occ

FB Fire Barrier

FSB Fire & Smoke Barrier

H/Exit Horizontal Exit

HAZ Hazardous

NR Non-Rated

S/Wall Suite Wall

SB Smoke Barrier

Door Operator

Code Operator Type

A Automatic

M Manual

P Power Operated

SW Self with Hold Open

SWO Self without Hold Open

Door Type

Code Door Type

DE Delayed Egress

DoE Double Egress

Sw Regular Swinging

Section IV Inspected Fire Door Inventory

Assembly

ID #

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0001 FD-232-5 1st Floor Cross corridors to South Wing Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0002 FD-232-2 1st Floor Cross corridors by Speech Pathology Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0003 FD-252-2 1st Floor Cross corridors by Main Lobby Smoke Barrier 3 Hour Metal Label Illegible Label Illegible

LLVA0004 FD-212-4 1st Floor Cross corridors to Module 3 2 Hour 90 Minutes Metal Label Illegible Label Illegible

LLVA0005 FD-272-2 1st Floor Cross corridors by South Elevator Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0006 FD-242-1 1st Floor Cross corridors by 1C-16 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0007 FD-222-4 1st Floor Cross corridors by NW Entrance Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0008 FD-262-4 1st Floor Cross corridors to Engineering 1 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0009 FD-212-3 1st Floor Cross corridors by North Elevator 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0012 FD-252-4 1st Floor Cross corridors to South Wing Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0014 C1-49 1st Floor CROSS CORRIDOR BY 1F-05 Smoke Barrier Label Not Required Metal 90 Minutes 90 Minutes

LLVA0015 FD-272-3 1st Floor Cross corridors to CLC 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0016 FD-282-2 1st Floor Cross corridors to 1SE Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0021 BY 1G-102 1st Floor Cross corridors to Patriot Place Smoke Barrier 3 Hour Metal 20 Minutes 20 Minutes

LLVA0022 BY 1G-101 1st Floor Cross corridors to Patriot Place Smoke Barrier 3 Hour Metal 20 Minutes 20 Minutes

LLVA0023 FD-382-3 1st Floor Cross corridors to 1SE Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0024 FD-382-1 1st Floor Cross corridors to 1SW Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0028 FD-253-1 2nd Floor Cross corridors by West Elevator 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0029 BY 1C-22 1st Floor Cross corridors by North Elevator Smoke Barrier 90 Minutes Metal Non Rated Smoke Non Rated Smoke D

LLVA0031 FD-262-1 1st Floor Cross corridors Main Hospital Smoke Barrier 90 Minutes Metal Non Rated Smoke Non Rated Smoke D

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

FIRE DOOR ASSEMBLY INVENTORY

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0032 FD-282-3 1st Floor SE Cross Corridors 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0034 FD-382-2 1st Floor Cross corridors by 1E-73 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0035 FD-243-1 2nd Floor Cross corridors to Cafeteria Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0036 FD-213-1 2nd Floor Cross corridors by 2A-15A Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0037 FD-233-2 2nd Floor Cross corridors 2A-29 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0042 FD-223-4 2nd Floor Cross corridors to Acute Psych Unit

2NE

2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0043 FD-243-3 2nd Floor Cross corridors by Staff Elevator Smoke Barrier Label Not Required Metal 90 Minutes 90 Minutes

LLVA0044 By Vending Machines

2nd Floor South Elevator Lobby Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0045 FD-243-2 2nd Floor Cross corridors by 2C-02 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0047 FD-223-5 2nd Floor Cross corridors by 2C-06B 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0049 C2-34 2nd Floor Cross corridors to Neurology Smoke Barrier 90 Minutes Wood 45 Minutes 45 Minutes

LLVA0050 2nd Floor Cross corridors to Mental Health 2NW 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0051 FD-224-1 3rd Floor North Elevator Lobby 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0052 FD-214-2 3rd Floor Cross corridors by 3B-08 Smoke Barrier 90 Minutes Metal 90 Minutes

LLVA0053 3A-26 3rd Floor MRI Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0055 C3-67A 3rd Floor Cross corridors by 3C-20 Smoke Barrier 90 Minutes, Listed Frame - No Rating Specified

Metal 90 Minutes 90 Minutes

LLVA0055a FD-274-1 3rd Floor SSU Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0057 FD-254-2 3rd Floor Cross corridors by 3F-41 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0058 FD-254-1 3rd Floor Cross corridors by 3A-63 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0060 C3-55 3rd Floor Cross corridors to X-Ray Smoke Barrier 90 Minutes Metal Non Rated Smoke Non Rated Smoke D

LLVA0061 FD-234-6 3rd Floor Cross corridors by 3E-39 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0062 FD-214-3 3rd Floor Cross corridors by 3B-48 Smoke Barrier 90 Minutes Wood 90 Minutes 90 Minutes

LLVA0063 FD-225-1 4th Floor North Elevator Lobby 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0064 FD-263-2 2nd Floor Cross corridors by Courtyard SE 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0065 FD-263-3 2nd Floor Cross corridors by 2C-24 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0066 C2-15 2nd Floor Entrance to Mental Health 2 Hour Missing Label PLAM 60 Minutes

LLVA0068 FD-234-3 3rd Floor Cross corridors by North Elevator Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0070 FD-234-2 3rd Floor Cross corridors by 3A-24 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0071 FD-224-3 3rd Floor Cross corridors to 3NE Clinics 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0072 FD-244-2 3rd Floor Cross corridors by 3C-01 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0074 C3-72 3rd Floor South Elevator Lobby Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0075 FD-244-1 3rd Floor Cross corridors by 3F-45B Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0076 FD-234-7 3rd Floor Cross corridors to X-Ray Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0077 FD-214-1 3rd Floor Cross corridors to 3NW Clinics 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0079 FD-234-5 3rd Floor Cross corridors by 3E-16 Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes 90 Minutes

LLVA0080 FD-235-3 4th Floor Cross corridors by North Elevator 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0081 FD-255-1 4th Floor Cross corridor by 4A-25 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0082 215-1 4th Floor Cross corridors by 4A-07 2 Hour 90 Minutes Metal 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0086 ST4-5 4th Floor Stair 5 2 Hour 90 Minutes Metal 90 Minutes

LLVA0087 C4-63 4th Floor Service Elevator Cross Corridor Non Rated Missing Label, Listed Frame - No Rating Specified

Metal Non Rated Smoke Non Rated Smoke D

LLVA0090 C4-38 4th Floor Cross corridors by Lab Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0091 FD-255-2 4th Floor Cross corridors by South Elevator 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0094 4th Floor Cross corridor by 4B-08 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0095 C4-14 4th Floor C Wing Cross corridors by 4C10 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0096 FD-265-2 4th Floor Cross corridors by 4C-32 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0097 FD-265-1 4th Floor South Elevator Lobby 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0098 C4-75 4th Floor Cross corridors by 4D-66 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0100 FD-235-2 4th Floor Cross corridor by 4E-39 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0101 FD-245-1 4th Floor Cross corridors by 4E-04 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0102 ST4-4 4th Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

LLVA0105 ST4-6 4th Floor Stair 6 2 Hour 90 Minutes Metal 90 Minutes

LLVA0106 ST4-6 4th Floor Stair 6 2 Hour 90 Minutes Metal 90 Minutes

LLVA0110 ST3-5 3rd Floor Stair 5 2 Hour 90 Minutes Metal 90 Minutes

LLVA0111 ST3-8 3rd Floor Stair 8 2 Hour 90 Minutes Metal 90 Minutes

LLVA0115 ST4-7 4th Floor Stair 7 2 Hour 90 Minutes Metal 90 Minutes

LLVA0116 Stair 1 4th Floor STR1 4-1 2 Hour 90 Minutes Metal 90 Minutes

LLVA0118 ST3-4 3rd Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0120 ST3-2 3rd Floor Stair 2 2 Hour 90 Minutes Metal 90 Minutes

LLVA0124 ST3-6 3rd Floor Stair 6 2 Hour 90 Minutes Metal 90 Minutes

LLVA0125 ST3-3 3rd Floor Stair 3 2 Hour 90 Minutes Metal 90 Minutes

LLVA0126 ST3-6 3rd Floor Stair 6 2 Hour 90 Minutes Metal 90 Minutes

LLVA0128 3F-45B 3rd Floor Holding/PACU Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0131 ST2-4 2nd Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

LLVA0132 ST2-6 2nd Floor Stair 6 2 Hour 90 Minutes Metal 90 Minutes

LLVA0133 ST2-3 2nd Floor Stair 3 2 Hour 90 Minutes Metal 90 Minutes

LLVA0134 ST2-5 2nd Floor Stair 5 2 Hour 90 Minutes Metal 90 Minutes

LLVA0141 ST1-3 1st Floor Stair 3 2 Hour 90 Minutes Metal 90 Minutes

LLVA0143 ST1-5 1st Floor Stair 5 2 Hour 90 Minutes Metal 90 Minutes

LLVA0145 ST3-7 3rd Floor Stair 7 2 Hour 90 Minutes Metal 90 Minutes

LLVA0146 ST3-1 3rd Floor Stair 1 2 Hour 90 Minutes Metal 90 Minutes

LLVA0148 FD234-4 3rd Floor Pain Clinic Smoke Barrier Label Not Required Metal 90 Minutes 90 Minutes

LLVA0154 ST2-1 2nd Floor Stair 1 2 Hour 90 Minutes Metal 90 Minutes

LLVA0161 ST1-5 1st Floor Stair 5 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0162 ST1-9 1st Floor Stair 9 - Up 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0163 BY 1A-56 1st Floor Cross corridors to ED Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0171 ST1-9 1st Floor Stair 9 - Down 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0180 FD-265-4 4th Floor Cross corridors by 4C-22 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0181 BY 3F-47 3rd Floor OR Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes 90 Minutes

LLVA0186 C1-53 1st Floor Cross corridors by 1f-10 Smoke Barrier Label Not Required Metal Non Rated Smoke Non Rated Smoke D

LLVA0187 C1-49 1st Floor Cross corridors by 1F-01 Smoke Barrier Label Not Required Metal Non Rated Smoke Non Rated Smoke D

LLVA0196 C1-40 1st Floor Wharehouse Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes 90 Minutes

LLVA0197 By 4C-01 4th Floor Cross corridors by Service Elevator Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0203 4th Floor Service Bay 2 1 Hour Missing Label Metal Missing Label

LLVA0203a ST1-4 1st Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

LLVA0204 1A-10 1st Floor Beneficiary Travel Smoke Barrier 90 Minutes Wood 90 Minutes

LLVA0205 1A-11 1st Floor Beneficiary Travel Smoke Barrier 90 Minutes Wood 90 Minutes

LLVA0206 1A-102 1st Floor 1A-102 Smoke Barrier 90 Minutes Wood 90 Minutes

LLVA0207 SB4-3 4th Floor Service Bay 3 1 Hour Missing Label Metal 90 Minutes

LLVA0208 1C-28 1st Floor Linen Supply Smoke Barrier Label Not Required Metal Non Rated Smoke Non Rated Smoke D

LLVA0209 1C-33 1st Floor Kitchen Smoke Barrier Label Not Required Metal Non Rated Smoke Non Rated Smoke D

LLVA0209a 4.00E-62 4th Floor Stress Lab Smoke Barrier 90 Minutes Wood 90 Minutes

LLVA0210 1C-32D 1st Floor Dish Room Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0211 SB4-7 4th Floor Service Bay 7 1 Hour Missing Label Metal Missing Label

LLVA0211a 1C-37 1st Floor 1C-37 Smoke Barrier Label Not Required PLAM 60 Minutes

LLVA0214 4th Floor Inside Stair 2 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0215 1F-43 1st Floor Office Smoke Barrier Listed Frame - No Rating Specified

Wood 45 Minutes

LLVA0216 C3-32 3rd Floor Resident Quarters 2 Hour Missing Label PLAM 90 Minutes

LLVA0216a C1-52 1st Floor Cross corridors by 1A-88 Smoke Barrier Label Not Required PLAM 90 Minutes

LLVA0217 ST3-4 3rd Floor Stair 4 2 Hour Listed Frame - No Rating Specified

Metal Missing Label

LLVA0217a 1A-84V 1st Floor Locker Room Smoke Barrier 90 Minutes PLAM 90 Minutes

LLVA0218 SB3-5 3rd Floor Service Bay 5 1 Hour Missing Label, Label Not Required

Metal Missing Label

LLVA0218a FD212-2 1st Floor Cross corridors to North Elevator 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0219 SB3-7 3rd Floor Service Bay 7 1 Hour Missing Label Metal Missing Label

LLVA0221 BY SERVICE

BAY 8

1st Floor SE Entrance 2 Hour Missing Label Metal Missing Label

LLVA0222 SB3-8 3rd Floor Service Bay 8 1 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0222a ST1-8 1st Floor Stair 8 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0223 SB3-6 3rd Floor Service Bay 6 1 Hour Missing Label Metal Missing Label

LLVA0223a 2A-217 2nd Floor Cross corridor to Patient Care Smoke Barrier 90 Minutes Wood 45 Minutes

LLVA0224 SB3-4 3rd Floor Service Bay 4 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0224a ST2-4 2nd Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

LLVA0225 C2-34 2nd Floor Elevator Lobby Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0225a 3C-11 3rd Floor Purchasing 2 Hour 90 Minutes Wood 90 Minutes 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0226 FD-223-1 2nd Floor North Elevator Lobby 2 Hour 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0230 BALCONY

ACCESS

2nd Floor Inside Stair 2 2 Hour Missing Label Metal Missing Label

LLVA0235 3rd Floor Inside Stair 8 2 Hour Label Not Required, Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0235a 2F-25 2nd Floor Kitchen Storage Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0236 ST4-8 4th Floor Inside Stair 8 2 Hour 90 Minutes, Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0237 MA-4-3 4th Floor Inside Stair 7 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0238 ACC02-7 2nd Floor Inside Stair 7 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0239 ST2-7 2nd Floor Stair 7 2 Hour 90 Minutes Metal 90 Minutes

LLVA0240 3rd Floor Inside Stair 7 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0241 ACC03-1 3rd Floor Inside Stair 1 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0242 Inside Stair 1 4th Floor ACC04-1 2 Hour 90 Minutes Wood 90 Minutes

LLVA0243 ACC02-1 2nd Floor Inside Stair 1 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0244 ACC03-2 3rd Floor Inside Stair 2 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0295 3A-63 3rd Floor Endoscopy Suite D Smoke Barrier 3 Hour Wood 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0298 3D-07 3rd Floor SICU Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0299 FD T-4 Basement Cross corridors by Tr4 Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0300 TR2 Basement Service Bay 4 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0301 FR2 Basement Service Bay 2 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0302 ST2 T1 Basement Stair 2 2 Hour Listed Frame - No Rating Specified

Metal Label Illegible

LLVA0303 TR4 Basement Service Bay 6 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0304 FR4 Basement Service Bay 8 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0305 ST8 T-1 Basement Stair 8 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0307 TO T3 TUNNEL Basement Cross corridor Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0308 GS6 Basement Bellsouth Comm System 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0309 TR1 Basement Service Bay 3 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0310 FR1 Basement Service Bay 1 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0311 1A Basement Stair 1 2 Hour Listed Frame - No Rating Specified

Metal Label Illegible

LLVA0312 Basement Cross corridors by SB5 Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0313 TR3 Basement Service Bay 5 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0314 FR3 Basement Service Bay 7 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0315 7A Basement Stair 7 2 Hour Listed Frame - No Rating Specified

Metal Label Illegible

LLVA0316 ST4-4 1st Floor Stair 4 2 Hour 90 Minutes Metal 90 Minutes

LLVA0317 PH3 Penthouse Penthouse 3 Stair 4 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0318 PH3 Penthouse Penthouse 3 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0319 PH-05 Penthouse Penthouse 5 Stair 5 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0320 PH-05 Penthouse Penthouse 5 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0321 Stairwell Penthouse Penthouse 7 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0322 PH-06 Penthouse Penthouse 6 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0327 Stairwell exit to Elevator Room

Penthouse Penthouse 2 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0328 PH-02 Penthouse Penthouse 2 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0353 SB3-1 3rd Floor Service Bay 1 1 Hour Missing Label Metal Missing Label

LLVA0387 SB4-8 4th Floor Service Bay 8 1 Hour Missing Label Wood 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0388 4A-24 4th Floor Nursing Admin Conference Room Smoke Barrier Listed Frame - No Rating Specified

Wood Non Rated Smoke

LLVA0391 By C2-85 2nd Floor Cross corridors to ICU 2 Hour 90 Minutes PLAM 90 Minutes 90 Minutes

LLVA0392 1A-404 1st Floor Men's Restroom Smoke Barrier Label Not Required PLAM Non Rated Smoke

LLVA0393 1A-403 1st Floor Womeb's Restroom Smoke Barrier Label Not Required PLAM Non Rated Smoke

LLVA0394 BY 1A-72 1st Floor Cross corridors to Exam Room 2 Hour Missing Label PLAM 20 Minutes

LLVA0396 1G-116 1st Floor Med Room Hazardous Room 3 Hour Wood 45 Minutes

LLVA0397 1G-114 1st Floor Clean Utility Hazardous Room 3 Hour Wood 45 Minutes

LLVA0398 1G-112 1st Floor Soiled Utility Hazardous Room 3 Hour Wood 45 Minutes

LLVA0399 1G-138 1st Floor Office Hazardous Room 3 Hour Wood Non Rated Smoke

LLVA0400 1G-143 1st Floor Laundry Hazardous Room 3 Hour Wood 45 Minutes

LLVA0402 2A-02 2nd Floor Men's Restroom Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0403 2A-01 2nd Floor Women's Restroom Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0404 3F-22 Interstitial Space

Nurse Manager Smoke Barrier 45 Minutes Metal 90 Minutes

LLVA0405 BY 3F-21 Interstitial Space

OR Cross Corridors Smoke Barrier 60 Minutes Metal 60 Minutes 60 Minutes

LLVA0407 4th Floor Stair 2 2 Hour 90 Minutes Metal 90 Minutes

LLVA0408 4F-01 4th Floor Microbiology Lab Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0409 4F-19 4th Floor CORE Lab Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0410 4F-20 4th Floor Procedure Room Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0411 SB4-6 4th Floor Service Bay 6 1 Hour Missing Label Wood 90 Minutes

LLVA0413 1st Floor Police Exit Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0414 1C-25 1st Floor Mail Room Smoke Barrier Listed Frame - No Rating Specified

Metal 20 Minutes

LLVA0415 1B-52 1st Floor Research Lab Smoke Barrier 90 Minutes Metal 90 Minutes

LLVA0416 1D-19 1st Floor Electric Room 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes 90 Minutes

LLVA0418 1D-01B 1st Floor Fire Pump Room 1 Hour Missing Label Metal Missing Label Missing Label

LLVA0420 1D-19 Interstitial Space

Generator 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0421 SB01-6A 1st Floor Equipment Room 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0501 Stair exit to Penthouse Penthouse 5 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0502 PH3 Penthouse Penthouse 3 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0503 SB4-4 4th Floor Service Bay 4 1 Hour Missing Label Metal 90 Minutes

LLVA0510 3.00E-01 3rd Floor Biomed Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0511 ST4-2 Interstitial Space

Stair 2 Interstitial 2 Hour Label Illegible Metal Label Illegible

LLVA0513 Service Bay by Stair 1

4th Floor SB04-1A 1 Hour Missing Label Wood 90 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0517 C4-26 4th Floor By Elevator 04-P2 Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0518 SB4-5 4th Floor Service Bay 5 1 Hour Missing Label Metal Missing Label

LLVA0525 4A-16 4th Floor 4A-16 Smoke Barrier Listed Frame - No Rating Specified

PLAM Non Rated Smoke

LLVA0526 4.00E-05 4th Floor Secretary Office 2 Hour 90 Minutes Metal 90 Minutes

LLVA0528 C4-77 4th Floor Cross corridors by 4D-45 Smoke Barrier 90 Minutes Metal 90 Minutes 90 Minutes

LLVA0529 ST4-8 4th Floor Stair 8 2 Hour 90 Minutes Metal 90 Minutes

LLVA0535 4.00E-10 4th Floor Office 2 Hour 90 Minutes Wood 90 Minutes

LLVA0536 4F-19 4th Floor CORE Lab Smoke Barrier 90 Minutes Wood 90 Minutes

LLVA0540 SB3-2 3rd Floor Service Bay 2 1 Hour Missing Label Metal Missing Label

LLVA0541 4D-57 4th Floor Clean Linen Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0542 4D-57 4th Floor Clean Linen Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0543 4D-58 4th Floor Clean Storage Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0543a 4D-58 4th Floor Clean Storage Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0545 4D-59 4th Floor Soiled Utility Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0546 4D-59 4th Floor Soiled Utility Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0547 4D-60 4th Floor Omnicell Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0548 4D-60 4th Floor Omnicell Hazardous Room 90 Minutes PLAM 60 Minutes

LLVA0549 SB2-7 2nd Floor Service Bay 7 1 Hour Missing Label Metal Missing Label

LLVA0550 1E—124 1st Floor Soiled Utility Hazardous Room Missing Label PLAM 60 Minutes

LLVA0551 1G-131 1st Floor Mechanical Room 1 Hour 3 Hour Metal 45 Minutes 45 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0552 1G-112 1st Floor Soiled Utility Hazardous Room 3 Hour Wood 60 Minutes

LLVA0553 1G-114 1st Floor Clean Utility Hazardous Room 3 Hour Wood 45 Minutes

LLVA0554 1G-116 1st Floor Med Room Hazardous Room 3 Hour Wood 45 Minutes

LLVA0555 SB1-8 1st Floor Service Bay 8 1 Hour Missing Label Metal Missing Label

LLVA0556 1C-04B 1st Floor Wharehouse Smoke Barrier Listed Frame - No Rating Specified

Wood Non Rated Smoke

LLVA0557 1C-33A 1st Floor Dish Room Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0558 1C-28C 1st Floor Linen Smoke Barrier Listed Frame - No Rating Specified

Metal Non Rated Smoke Non Rated Smoke D

LLVA0559 1C-27 1st Floor Pharmacy Smoke Barrier Listed Frame - No Rating Specified

Metal 45 Minutes

LLVA0560 1B-46B 1st Floor 1B-46B Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0561 SB1-2 1st Floor Service Bay 2 1 Hour Missing Label Metal Missing Label

LLVA0562 ST1-2 1st Floor Stair 2 2 Hour Missing Label Metal 90 Minutes

LLVA0563 ACC02-2 2nd Floor Inside Stair 2 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0564 SB2-2 2nd Floor Service Bay 2 1 Hour Missing Label Metal Missing Label

LLVA0565 BY 1A-634 1st Floor ED Suite Door Smoke Barrier Label Not Required Metal 20 Minutes 20 Minutes

LLVA0566 1st Floor Cross corridors by 1A-305 Smoke Barrier 3 Hour PLAM 45 Minutes 45 Minutes

LLVA0567 ED WAITING

AREA

1st Floor Cross corridors to ED Smoke Barrier 3 Hour PLAM 45 Minutes 45 Minutes

LLVA0568 1A-277 1st Floor CT Scan Smoke Barrier 90 Minutes PLAM 20 Minutes 20 Minutes

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0569 1A-276 1st Floor X-Ray Smoke Barrier 90 Minutes PLAM 45 Minutes 45 Minutes

LLVA0570 VACCINE CLINIC 1st Floor Cross corridors by 1A-109 Smoke Barrier Label Not Required PLAM 20 Minutes

LLVA0581 1C-38 1st Floor Housekeeping Smoke Barrier Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0616 GS5 Basement Service Bay 3 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0617 ST1-1 1st Floor Stair 1 2 Hour Missing Label Metal 90 Minutes

LLVA0618 SB1-1 1st Floor Service Bay 1 1 Hour Missing Label Metal Missing Label

LLVA0619 ST9 T-1 Basement Stair 9 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0620 ST2-9 2nd Floor Stair 9 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0701 ST1-7 1st Floor Stair 7 2 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA0703 SB1-7 1st Floor Service Bay 7 1 Hour Missing Label Metal Missing Label

LLVA0911 3.00E-38 3rd Floor Vestibule Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0912 3E-28E 3rd Floor Reading Room Smoke Barrier Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0913 3C-21B 3rd Floor Men's Restroom 2 Hour 90 Minutes Metal 90 Minutes

LLVA0914 SB2-3 2nd Floor Service Bay 3 1 Hour Missing Label Metal Missing Label

LLVA0915 C-109 2nd Floor Mental Health 2 Hour Listed Frame - No Rating Specified

PLAM 60 Minutes

LLVA0916 SB2-5 2nd Floor Service Bay 5 1 Hour Missing Label Metal Missing Label

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Facility Unique ID # Floor

Location (Specific)

Purpose of Assembly

Frame Rating (Min.)

Door Construction

Door 1 Rating (Minutes)

Door 2 Rating (Minutes)

LLVA0917 SB2-5 2nd Floor Service Bay 5 1 Hour Missing Label Metal Missing Label

LLVA0918 SB2-6 2nd Floor Service Bay 6 1 Hour Missing Label Metal Missing Label

LLVA0919 ST2-8 2nd Floor Inside Stair 8 2 Hour Listed Frame - No Rating Specified

Wood 90 Minutes

LLVA0920 SB2-8 2nd Floor Service Bay 8 1 Hour Missing Label Wood 20 Minutes

LLVA0921 South Elevator Lobby

2nd Floor Cross corridors to ICU 2SE & 2SW 2 Hour 90 Minutes PLAM 90 Minutes 90 Minutes

LLVA0922 By C-282A 2nd Floor Cross corridors to ICU 2 Hour 90 Minutes PLAM 90 Minutes 90 Minutes

LLVA0923 ST2-8 2nd Floor Stair 8 2 Hour 90 Minutes Metal 90 Minutes

LLVA0926 3C-12 3rd Floor Clean Storage 2 Hour 90 Minutes Wood 90 Minutes

LLVA0927 SB3-3 3rd Floor Service Bay 3 1 Hour Missing Label Metal Missing Label

LLVA0929 3rd Floor Restroom by Stair 4 Smoke Barrier Label Not Required Metal Non Rated Smoke

LLVA0930 SB2-1 2nd Floor Service Bay 1 1 Hour Missing Label Metal Missing Label

LLVA1072 BY SB01-6A 1st Floor AHU 2 Hour Missing Label Metal 90 Minutes

LLVA1077 SB1-2 Interstitial Space

Service Bay 2 1 Hour Listed Frame - No Rating Specified

Metal 90 Minutes

LLVA1096 ST2-2 2nd Floor Stair 2 2 Hour 90 Minutes Metal 90 Minutes

LLVA1098 BY 1D-01 1st Floor Storage 1 Hour Listed Frame - No Rating Specified

Metal 45 Minutes

LLVA1100 1B-04A 1st Floor Seclusion Smoke Barrier 90 Minutes Wood 90 Minutes

Inventory Assemblies: 0 Inspection Assemblies: 275 Inspection 2nd Leaf: 93 Total Inspected Doors: 368

VA Loma Linda

INVENTORY DATE: 11/14/2022 TO 11/21/2022

Section V Discrepancy Count by Type

Incorrect Door Clearances

Door 1 - Incorrect Clearance - Top of door to frame 15

Door 1 - Incorrect Clearance - Latch edge of door to frame 16

Door 2 - Incorrect clearance - Top of door to frame 2

Frame and Door Labels

Door 1 - Label is missing/painted/illegible

Door 2 - Label is missing/painted/illegible

Frame - label is missing/painted/illegible

Open/Unused holes:

Door 1 - Open or unused fastener holes

Door 2 - Open or unused fastener holes

Frame - Open or unused fastener holes

Missing/Incorrect/Loose Fasteners

VA Loma Linda

INSPECTION DATE: 11/14/2022 TO 11/21/2022

INSPECTION REPORT DISCREPANCY COUNT

Hinge - missing/incorrect fastners

Fire Exit Hardware - Missing/incorrect fasteners

Hinge - Not securely fastened

General

Frame - Not securely attached to wall

Fire Exit Hardware - Not securely fastened

Seal - Incorrect/missing/damaged

Door does not latch reliably

Door is being held open

Door is insufficiently rated

Total Discrepancies:

Section VI Discrepancy Count by Assembly ID#

Facility Unique ID Floor

Specific Location

Purpose of Assembly Discrepancy

LLVA0001FD-232-5 1st Floor Cross corridors to South Wing Smoke Barrier Compliant

LLVA0002FD-232-2 1st Floor Cross corridors by Speech Pathology

Smoke Barrier Compliant

LLVA0003FD-252-2 1st Floor Cross corridors by Main Lobby Smoke Barrier Compliant

LLVA0004FD-212-4 1st Floor Cross corridors to Module 3 2 Hour Door 1 - Label is missing/painted/illegible

Door 2 - Label is missing/painted/illegible

LLVA0005FD-272-2 1st Floor Cross corridors by South Elevator

Smoke Barrier Compliant

LLVA0006FD-242-1 1st Floor Cross corridors by 1C-16 Smoke Barrier Compliant

LLVA0007FD-222-4 1st Floor Cross corridors by NW Entrance

Smoke Barrier Compliant

LLVA0008FD-262-4 1st Floor Cross corridors to Engineering 1 Hour Compliant

LLVA0009FD-212-3 1st Floor Cross corridors by North Elevator

2 Hour Compliant

LLVA0012FD-252-4 1st Floor Cross corridors to South Wing Smoke Barrier Compliant

LLVA0014C1-49 1st Floor CROSS CORRIDOR BY 1F-05 Smoke Barrier Compliant

LLVA0015FD-272-3 1st Floor Cross corridors to CLC 2 Hour Compliant

LLVA0016FD-282-2 1st Floor Cross corridors to 1SE Smoke Barrier Compliant

LLVA0021BY 1G-102 1st Floor Cross corridors to Patriot Place

Smoke Barrier Compliant

LLVA0022BY 1G-101 1st Floor Cross corridors to Patriot Place

Smoke Barrier Compliant

LLVA0023FD-382-3 1st Floor Cross corridors to 1SE Smoke Barrier Compliant

VA Loma Linda

INSPECTION DATE: 11/14/2022 TO 11/21/2022

Discrepancy Count By Assembly ID # Inspection

Facility Unique ID Floor

Specific Location

Purpose of Assembly Discrepancy

LLVA0024FD-382-1 1st Floor Cross corridors to 1SW Smoke Barrier Compliant

LLVA0028FD-253-1 2nd Floor Cross corridors by West Elevator

2 Hour Compliant

LLVA0029BY 1C-22 1st Floor Cross corridors by North Elevator

Smoke Barrier Compliant

LLVA0031FD-262-1 1st Floor Cross corridors Main Hospital Smoke Barrier Compliant

LLVA0032FD-282-3 1st Floor SE Cross Corridors 2 Hour Compliant

LLVA0034FD-382-2 1st Floor Cross corridors by 1E-73 Smoke Barrier Compliant

LLVA0035FD-243-1 2nd Floor Cross corridors to Cafeteria Smoke Barrier Compliant

LLVA0036FD-213-1 2nd Floor Cross corridors by 2A-15A Smoke Barrier Compliant

LLVA0037FD-233-2 2nd Floor Cross corridors 2A-29 Smoke Barrier Compliant

LLVA0042FD-223-4 2nd Floor Cross corridors to Acute Psych Unit 2NE

2 Hour Door does not latch reliably

LLVA0043FD-243-3 2nd Floor Cross corridors by Staff Elevator

Smoke Barrier Compliant

LLVA0044By Vending Machines 2nd Floor South Elevator Lobby Smoke Barrier Compliant

LLVA0045FD-243-2 2nd Floor Cross corridors by 2C-02 Smoke Barrier Compliant

LLVA0047FD-223-5 2nd Floor Cross corridors by 2C-06B 2 Hour Compliant

LLVA0049C2-34 2nd Floor Cross corridors to Neurology Smoke Barrier Door does not latch reliably

LLVA0050 2nd Floor Cross corridors to Mental Health 2NW

2 Hour Compliant

LLVA0051FD-224-1 3rd Floor North Elevator Lobby 2 Hour Compliant

LLVA0052FD-214-2 3rd Floor Cross corridors by 3B-08 Smoke Barrier Seal - Incorrect/missing/damaged

VA Loma Linda

INSPECTION DATE: 11/14/2022 TO 11/21/2022

Discrepancy Count By Assembly ID #

Facility Unique ID Floor

Specific Location

Purpose of Assembly Discrepancy

LLVA00533A-26 3rd Floor MRI Smoke Barrier Compliant

LLVA0055C3-67A 3rd Floor Cross corridors by 3C-20 Smoke Barrier Compliant

LLVA0055aFD-274-1 3rd Floor SSU Smoke Barrier Door 1 - Incorrect Clearance - Top of door to frame

Door 2 - Incorrect clearance - Top of door to frame

LLVA0057FD-254-2 3rd Floor Cross corridors by 3F-41 Smoke Barrier Compliant

LLVA0058FD-254-1 3rd Floor Cross corridors by 3A-63 Smoke Barrier Compliant

LLVA0060C3-55 3rd Floor Cross corridors to X-Ray Smoke Barrier Compliant

LLVA0061FD-234-6 3rd Floor Cross corridors by 3E-39 Smoke Barrier Compliant

LLVA0062FD-214-3 3rd Floor Cross corridors by 3B-48 Smoke Barrier Hinge - missing/incorrect fastners

Fire Exit Hardware - Not securely fastened

LLVA0063FD-225-1 4th Floor North Elevator Lobby 2 Hour Compliant

LLVA0064FD-263-2 2nd Floor Cross corridors by Courtyard

SE

2 Hour Compliant

LLVA0065FD-263-3 2nd Floor Cross corridors by 2C-24 2 Hour Compliant

LLVA0066C2-15 2nd Floor Entrance to Mental Health 2 Hour Frame - label is missing/painted/illegible

LLVA0068FD-234-3 3rd Floor Cross corridors by North Elevator

Smoke Barrier Compliant

LLVA0070FD-234-2 3rd Floor Cross corridors by 3A-24 Smoke Barrier Compliant

LLVA0071FD-224-3 3rd Floor Cross corridors to 3NE Clinics 2 Hour Compliant

LLVA0072FD-244-2 3rd Floor Cross corridors by 3C-01 Smoke Barrier Compliant

LLVA0074C3-72 3rd Floor South Elevator Lobby Smoke Barrier Door does not latch reliably

LLVA0075FD-244-1 3rd Floor Cross corridors by 3F-45B Smoke Barrier Compliant

LLVA0076FD-234-7 3rd Floor Cross corridors to X-Ray Smoke Barrier Compliant

VA Loma Linda

INSPECTION DATE: 11/14/2022 TO 11/21/2022

Discrepancy Count By Assembly ID #

Facility Unique ID Floor

Specific Location

Purpose of Assembly Discrepancy

LLVA0077FD-214-1 3rd Floor Cross corridors to 3NW Clinics 2 Hour Compliant

LLVA0079FD-234-5 3rd Floor Cross corridors by 3E-16 Smoke Barrier Compliant

LLVA0080FD-235-3 4th Floor Cross corridors by North Elevator

2 Hour Compliant

LLVA0081FD-255-1 4th Floor Cross corridor by 4A-25 Smoke Barrier Compliant

LLVA0082215-1 4th Floor Cross corridors by 4A-07 2 Hour Compliant

LLVA0086ST4-5 4th Floor Stair 5 2 Hour Compliant

LLVA0087C4-63 4th Floor Service Elevator Cross Corridor Non Rated Compliant

LLVA0090C4-38 4th Floor Cross corridors by Lab Smoke Barrier Compliant

LLVA0091FD-255-2 4th Floor Cross corridors by South Elevator

2 Hour Compliant

LLVA0094 4th Floor Cross corridor by 4B-08 Smoke Barrier Compliant

LLVA0095C4-14 4th Floor C Wing Cross corridors by 4C10

2 Hour Compliant

LLVA0096FD-265-2 4th Floor Cross corridors by 4C-32 2 Hour Compliant

LLVA0097FD-265-1 4th Floor South Elevator Lobby 2 Hour Compliant

LLVA0098C4-75 4th Floor Cross corridors by 4D-66 Smoke Barrier Compliant

LLVA0100FD-235-2 4th Floor Cross corridor by 4E-39 Smoke Barrier Compliant

LLVA0101FD-245-1 4th Floor Cross corridors by 4E-04…