(a) Fire Safety and Emergency Plan. All assisted living facilities shall maintain a current written
fire safety, relocation, and evacuation plan. In facilities which do not have multiple smoke compartments, an
evacuation floor plan shall be appropriately posted in a conspicuous place.
(b) Fire Drills. Fire drills shall be conducted at least once per month in all facilities at varying times
and days and quarterly on each shift of Group and Congregate facilities. All fire drills shall be initiated
by the fire alarm system. The drills may be announced in advance to the residents. The drills shall involve the
actual evacuation of residents to assembly areas in adjacent smoke compartments or to the exterior as specified
in the emergency plan to provide staff and residents with experience in exiting through all exits required by the
currently adopted Life Safety Code. Written observations of the effectiveness of the fire drill plan shall be assessed
monthly, filed, and kept for at least three years.
(c) Fire Drills During Resident Sleeping Hours. When drills are conducted between 9 PM and 6 AM, a coded
announcement shall be permitted to be used instead of the normal audible fire alarm signals. These drills may be
conducted without disturbing sleeping residents, by using simulated residents or empty wheelchairs.
(d) Roller latches are prohibited on doors separating corridors from adjacent spaces.
(e) If alcohol-based hand rub dispensers are used in the facility, the dispensers must be installed in a
1. Minimizes leaks and spills.
2. Adequately protects against in appropriate access access.
3. Complies with the requirements of the
currently adopted Life Safety Code.
(f) Fire Alarm and Sprinkler System.
1. Fire Alarm System. Where fire alarm systems are required, a corridor smoke detection system shall be
installed on each floor, including areas open to the exit access corridor, to comply with NFPA 72, connected to the
facility’s fire alarm system. In lieu of corridor smoke detection, smoke detectors connected to the building fire
alarm system may be installed in each resident’s room, open areas, and at smoke doors (except that corridor smoke
detection shall not be deleted when its use is dictated by other requirements).
2. Fire alarm and sprinkler system outages of more than 4 hours require evacuation of the facility or the
establishment of a continuous fire watch. The fire watch procedure must be coordinated with the Department and the local Fire Marshal. Outages and fire watch documentation shall be reported to the Department within 12 hours or no later than the next duty day, and shall be corrected expeditiously.
3. The fire alarm system and the sprinkler system shall be inspected by licensed, trained, and
qualified personnel at least semiannually for compliance with the respective codes. Inspection and testing reports
shall be maintained in the facility for a period of at least 3 years.