Pascal Bergeron
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a. General. The concept of the National Fire Protection Association (NFPA) 101 Life Safety
Code requirements for fire safety with regard to the residents, is based on evacuation
capability. In accordance with NFPA 101, Chapters 32 and 33, Type A facilities are
classified as “slow” evacuation capability and Type B facilities are classified as
“impractical” evacuation capability.
b. Evacuation procedures. A resident in a Type A facility must be able to demonstrate to the
Texas Department of Aging and Disability Services (DADS) that the resident can travel
from the resident’s living unit to a centralized space, such as lobby, living or dining room
on the level of discharge within a 13-minute period without continuous staff assistance.
Elevators cannot be used as an evacuation route.
c. Operational features.
1. A fire causing damage to the facility or equipment must be reported to DADS
within 72 hours after the fire is extinguished. A fire causing injury or death to a
resident must be reported immediately. A telephone report must be followed by a
written report on a form that DADS supplies.
2. Fire drills must be conducted quarterly on each shift and with at least one drill
conducted each month. The drills may be announced in advance to the residents.
The drills must involve the participation of the staff in accordance with the
emergency plan. Residents must be informed of evacuation procedures and
locations of exits. All fire drills must be documented on a form provided by
DADS. In large Type B facilities, the drill must include the activation of the fire
alarm signal, except between 9:00 p.m. and 6:00 a.m.
3. Smoking regulations must be established, and smoking areas must be designated
for residents and staff. Ashtrays of noncombustible material and safe design must
be provided in smoking areas.
4. All facilities, except small, one-story facilities, must post an emergency
evacuation floor plan.
5. An assisted living facility must have in effect and available to all supervisory
personnel written copies of an evacuation plan for the protection of all persons in
the facility in the event of fire. The plan must address sheltering in place,
evacuation to an area of refuge, and evacuation from the building when necessary.
The plan must include special staff actions including fire protection procedures
needed to ensure the safety of any resident. The plan must be amended or revised
when needed. All employees must be periodically instructed and informed of their
duties and responsibilities under the plan. A copy of the plan must be readily
available at all times within the facility. The plan must reflect the current
evacuation capabilities of the residents.
d. Safety operations. The facility must have a written emergency preparedness and response
plan. The facility must attach to the plan the procedures the staff must follow. The plan
must address, at a minimum, the eight core functions of emergency management, which
are: direction and control; warning (how the facility will be notified of emergencies and
who they will notify); communication (with whom and by what mechanism); sheltering
arrangements; evacuation (destinations, routes); transportation; health and medical needs;
and resource management (supplies, staffing, emergency equipment, records). Plans must
be coordinated with the local emergency management coordinator and should address
those natural, technological and man-made emergencies that could affect the facility.
Information about the local emergency management coordinator may be obtained from
the office of the local mayor or county judge.
e. Construction.
1. An assisted living facility must be separated from other occupancies. A common
wall between an assisted living facility and another occupancy must be not less
than a two-hour fire-rated partition. The partition must be constructed as required
by National Fire Protection Association Standards. A licensed nursing facility or
licensed hospital is not considered another occupancy for this purpose. An
exception occurs when an occupancy not subject to DADS licensing standards is
located in the same building or structure and is so intermingled that a two hour
fire rated partition is impracticable. The means of egress, construction, protection
and other safeguards for that location must comply with the National Fire
Protection Association (NFPA) 101 requirements of the licensed occupancy.
2. Interior wall and ceiling surfaces must have as the finished surface or as substrate
or sheathing a fire resistance of not less than that provided by 3/8″ gypsum board
(20 minute fire rating), unless approved otherwise by DADS. A sprinkler system
will not substitute for the minimum construction requirements. Exceptions are
existing Type B large facilities must meet the construction requirements of NFPA
101, Chapter 19.1.6 and new Type B large facilities must meet NFPA 101,
Chapter 18.1.6.
3. An assisted living facility must meet flame spread rate requirements as specified
in Chapters 18, 19, 32, and 33 of NFPA 101.
4. Doors between resident rooms and corridors or public spaces must be not less
than 1-3/4″ thick solid core wood construction or 20-minute fire-rated, selfclosing or automatic-closing, and latch in their frames. Exceptions are as follows.
A. Small Type A facilities may have smoke resisting doors, with self-closing
or automatic closing devices, if the interior finish is Class ‘B’ or better and
there are two remote exit routes.
B. Small Type A facilities that have 20-minute fire-rated doors or 1-3/4″
solid core wood, Class ‘B’ or better interior finish, and two remote exit
routes are not required to have self-closing or automatic-closing doors.
C. In a small or large Type A facility protected throughout by an approved
automatic sprinkler system, doors to resident bedrooms are not required to
be self-closing or automatic-closing, except for a three story or larger
building that does not meet construction requirements of NFPA 101,
Chapter 18 70
D. In a small or a large Type B facility protected throughout by an approved
automatic sprinkler system, the facility may have smoke resisting doors.
Door-closing devices are not required.
5. Upper floors of an assisted living facility must have at least two separate
approved stairs. Each stair must be arranged and located so that it is not necessary
to go through another room, including a bedroom or bathroom, to reach the stair.
All stairs must be provided with handrails and with normal lighting. Refer to
NFPA 101 for Class ‘A’ stair details. DADS may exempt an existing facility with
16 beds or less from meeting this requirement. In the facility, at least one main
stair may be Class ‘B’ and constructed of wood.
6. All hazardous areas, as defined in NFPA 101, Chapter 18, 19, 32, or 33, must
have a one-hour fire-separated barrier or have sprinkler protection, or both, if
considered severe. Gasoline, volatile materials, oil base paint, charcoal lighter
fluid, or similar products must not be stored in the building housing residents.
7. Exit signs, with emergency power, must be provided in all large facilities and
installed in accordance with NFPA 101, §7.10.
8. Emergency lighting must be provided in all buildings with 25 or more rooms; in
apartment buildings with 12 or more living units or that are three or more stories
high; and in all large facilities that are designed for Type B. The system must be
installed in accordance with NFPA 101, §7.9.
9. Emergency motor generators, if required or provided, must be installed in
accordance with NFPA 37 or NFPA 110 or other applicable NFPA code or
f. Fire alarm and sprinkler systems.
1. Fire alarm and smoke detection system. An assisted living facility must install an
underwriter’s laboratory (U.L.) listed manual fire alarm initiating system, with an
interconnected automatic smoke detection and alarm initiation system, that
complies with the NFPA 101, §9.6. The operation of any alarm initiating device
must activate an audible or visual alarm at the site.
A. Smoke detectors must be installed in resident bedrooms, corridors,
hallways, living rooms, dining rooms, offices, and public or common
areas. Kitchens, laundries, and attached garages used for car parking may
have heat detectors in lieu of smoke detectors. Exceptions are as follows.
i. A large facility with apartment units may use listed smoke
detectors with an alarm device and separate heat detector contacts
in the living area. The smoke detector must emit an audible signal
within the apartment, and annunciate at the main staff station or
location. The heat detector contacts must be connected into the fire
alarm system and provide a general alarm when activated.
ii. A facility constructed to meet the requirements of NFPA 101,
Chapter 18, must meet § for smoke detector locations.
iii. A facility constructed to meet the requirements of NFPA 101,
Chapter 19, must meet § for smoke detector locations.71
B. The fire alarm control panel must be visible to staff at or near the staff
area that is attended 24 hours a day. An exception to this requirement is a
fire alarm control panel that is monitored by a device carried by the staff.
C. The primary power source for the complete fire alarm system must be
commercial electric and permanently wired for power on a dedicated
circuit in accordance with the National Electrical Code.
D. An emergency power source must be from approved storage batteries or
on-site engine-driven generator set.
E. The facility must have a written contract with a fire alarm firm which has
been issued an Alarm Certificate of Registration (ACR) number from the
Texas State Fire Marshal’s Office to perform the inspection, test and
maintenance requirements of NFPA 72 semiannually. Inspections
stipulated in the contract must be performed. The person performing the
semiannual service must have an individual fire alarm license from the
Texas State Fire Marshal’s Office. All other NFPA 72 requirements must
be performed and documented by a knowledgeable individual.
F. Smoke detector sensitivity must be checked within one year after
installation and every alternate year thereafter in accordance with NFPA
72. Documentation, including as-built installation drawings, operation and
maintenance manuals, and a written sequence of operation, must be
available for examination by DADS.
G. In large facilities, the fire alarm panel must indicate as a separate zone,
each floor and smoke compartment as applicable. Each zone must have an
alarm and trouble indication. Identification by zone is not required where
all alarm initiating devices are addressable and the status of each device is
identified on the fire alarm panel.
H. In large Type B facilities the fire alarm must automatically notify the fire
department in accordance with NFPA 101, §9.6.4.
2. Sprinkler systems. When installed or required, sprinkler systems must be
inspected, tested, and maintained in accordance with NFPA 25. The facility must
have a written contract with a fire protection sprinkler firm that has been issued a
Sprinkler Certificate of Registration number (SCR) from the Texas State Fire
Marshal’s Office to perform the required services semiannually. The facility must
have documentation available to show that all the requirements of NFPA 25 have
been met including the annual inspection, test, and maintenance by the registered
fire sprinkler firm. The facility must retain one set of the fire sprinkler system
plans and hydraulic calculations on the property in accordance with NFPA 25.
A. An existing small Type A facility housing 16 or fewer residents may have
a system that meets NFPA 13, 13D, or 13R requirements.
B. A new small Type A facility housing 16 or fewer residents must have a
system that meets NFPA 13, 13D, or 13R requirements, installed in
accordance with §
C. An existing small Type B facility housing 16 or fewer residents must be
protected by a sprinkler system that meets the requirements of NFPA 13, 72
13D, or 13R with additional requirements for coverage in all habitable areas and closets as specified by NFPA 101, §
D. A new small Type B facility housing 16 or fewer residents must be
protected by a sprinkler system that meets the requirement of NFPA 13,
NFPA 13R, or NFPA 13D, with additional requirements for coverage in
all habitable areas and closets as specified by NFPA 101, §
E. A new and an existing large Type B facility must have a complete
sprinkler system that meets the requirements of the NFPA 13.
F. An existing large Type A facility may have an NFPA 13 system. In a
building not more than four stories high an NFPA 13R system may be
G. A new large Type A facility must have an NFPA 13 system, however a
building not more than four stories high may have an NFPA 13R system.
g. Site and location.
1. The facility must be serviced by a paid or volunteer firefighting unit. Water
supply for firefighting purposes must be as required and approved by the
firefighting unit.
2. The facility must correct any site or building conditions determined by DADS to
be a fire, health, or physical hazard.
3. The facility must provide or arrange for nearby parking spaces for private vehicles
of residents and visitors. A minimum of one space must be provided for each four
beds or fraction thereof, or per local code, whichever is more stringent.
4. The facility must ensure that ramps, walks, and steps are of slip-resistive texture
and uniform, without irregularities. Ramps must not exceed 1:12 slope, and must
meet Texas Accessibility Standards for width. Guardrails, fences, or handrails
must be provided where grades make an abrupt change in level.
5. The facility must ensure that all outside areas, grounds, and adjacent buildings are
maintained in good condition and kept free of rubbish, garbage, untended growth
that may constitute a fire or health hazard. Site grades must provide for water
drainage away from the structure to prevent ponding or standing water at or near
the building.
h. Sanitation and housekeeping.
1. Wastewater and sewage must be discharged into an approved sewerage system or
an onsite sewerage facility approved by the Texas Commission on Environmental
Quality or its authorized agent.
2. The water supply must be of safe, sanitary quality, suitable for use, and adequate
in quantity and pressure, and obtained from a water supply system. The location,
construction, and operation of the water supply system must be approved by DADS.
3. Waste, trash, and garbage must be disposed of from the premises at regular
intervals in accordance with state and local requirements. Excessive
accumulations are not permitted. The facility must comply with 25 TAC §§1.131-
1.137 (relating to Definition, Treatment, and Disposition of Special Waste from
Health Care Related Facilities).
4. Operable windows must be insect screened.73
5. An ongoing pest control program must be provided by facility staff or by contract
with a licensed pest control company. The least toxic and least flammable
effective chemicals must be used.
6. Bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled and
unsanitary operations must be ventilated with operable windows. Bathrooms
without operable windows must have powered exhaust vented to the exterior for
odor control. An exception is granted for small facilities that vent into an attic in
accordance with the International Building Code or local building code.
7. In kitchens and in laundries, there must be procedures utilized by facility staff to
avoid cross-contamination between clean and soiled utensils and linens.
8. The facility must be kept free of accumulations of dirt, rubbish, dust, and hazards.
Floors must be maintained in good condition and cleaned regularly. Walls and
ceilings must be structurally maintained, repaired, and repainted or cleaned as
needed. Storage areas and cellars must be kept in an organized manner. No
storage will be permitted in the attic spaces.
9. The facility must be ventilated through the use of windows, mechanical
ventilation, or a combination of both. Interior areas designated for smoking within
the building must have mechanical ventilation directed to the exterior to remove
smoke at the rate of 10 air changes per hour.
10. In addition to a janitor closet required in specific departments of large facilities,
other janitor closets must be provided throughout the facility to maintain a clean
and sanitary environment. Each janitor closet must have a service sink and forced
air ventilation ducted to the outside.
11. A large facility with 60 beds or less must provide a toilet, including a commode
and lavatory, for use by the public and facility staff. A facility that has more than
60 beds must have separate public and staff toilets in addition to the staff toilets
required for the dietary staff. Toilets must comply with accessibility standards.
12. If the facility provides linens to the residents, the quantity of available linen must
meet the sanitary and cleanliness needs of the residents. Clean linens must be
stored in a clean area.
i. General safety features.
1. The facility must have an annual inspection by the local fire marshal.
2. The building must be kept in good repair. Electrical, heating, and cooling systems
must be maintained in a safe manner. DADS may require the facility sponsor or
licensee to submit evidence to this effect, consisting of a report from the fire
marshal, city or county building official having jurisdiction over the location of
the facility, licensed electrician, or a registered professional engineer. Use of
electrical appliances, devices, and lamps must not overload circuits or cause
excessive lengths of extension cords.
3. Existing furnace and water heater installations may be continued in service,
subject to approval by DADS.
4. In a large Type B facility, all draperies and other window coverings in public or
common areas, bedrooms, and living units must be flame resistant. In a large
Type A facility, draperies must be flame resistant, where smoking is permitted.
5. In an existing large facility, all new floor carpet installed in public or common
spaces after DADS performs the initial inspection must be classified as Class I or
II based on the “Critical Radiant Flux” ratings as required by NFPA 101, §10.2.7.
The facility must provide proper documentation by the carpet manufacturer.
6. Open flame heating devices are prohibited. All fuel burning heating devices must
be vented. Working fireplaces are acceptable if of safe design and construction
and if screened or otherwise enclosed.
7. There must be at least one telephone in the facility available to both staff and
residents for use in case of an emergency. Emergency telephone numbers,
including fire, police, ambulance, EMS, and poison control center, must be posted
conspicuously at or near the telephone.
8. An initial pressure test of facility gas lines from the gas meter must be provided.
Additional pressure tests will be required when the facility has major renovations
or additions where the gas service is interrupted. All gas heating systems must be
checked prior to the heating season for proper operation and safety by persons
who are licensed or approved by the State of Texas to inspect the equipment. A
record of the testing of the gas heating system must be maintained by the facility.
The facility must correct unsatisfactory conditions promptly.
9. Exterior and interior stairs must have handrails that are firmly secured to prevent falls.
10. Cooling and heating must be provided for resident comfort. Air conditioning
systems must be capable of maintaining the comfort ranges of 68 degrees
Fahrenheit to 82 degrees Fahrenheit in resident-use areas. A facility constructed
or licensed after August 1, 2004, must have a central air conditioning system, or a
substantially similar air conditioning system, that is capable of maintaining a
temperature suitable for resident comfort within areas used by residents. Heating,
ventilating, and air conditioning (HVAC) equipment must comply with the
requirements of NFPA 90A or 90B, as applicable. NFPA 90A requires automatic
shut down upon activation of the fire alarm in HVAC systems of over 2,000 cubic
feet per minute (cfm) capacity.
11. The Illumination Engineering Society of North America recommendations must
be followed to achieve proper illumination characteristics and lighting levels
throughout the facility. Minimum illumination must be 10 footcandles in resident
rooms during the day and 20 footcandles in corridors, staff stations, dining rooms,
lobbies, toilets, bathing facilities, laundries, stairways and elevators during the
day. Illumination requirements for these areas apply to lighting throughout the
space and should be measured at approximately 30 inches above the floor
anywhere in the room. Minimum illumination for medication preparation or
storage areas, kitchens, and staff station desks must be 50 footcandles during the
day. Illumination requirements for these areas apply to the task performed and
should be measured on the tasks.
12. All buildings three stories or higher and facilities that provide services, treatment,
or social activities on floors above or below the level of discharge and house
mobility impaired residents must have a passenger elevator. The lowest level of
discharge will be the first floor for determining floor level.
13. Floor, ceiling, and wall finish materials must be complete and in place to provide
a sanitary and structurally safe environment. 75
14. All equipment requiring periodic maintenance, testing, and servicing must be
reasonably accessible. Necessary equipment to conduct maintenance, testing, and
servicing, including ladders, specific tools, and keys, must be readily available on
site. Access panels (20″ x 20″ minimum) must be provided for building
maintenance and must be located for reasonable access to equipment or barriers
installed in the attic or other concealed spaces.
15. The facility must implement procedures that comply with the standards and
recommendations of the Compressed Gas Association to assure safe and sanitary
use and storage of oxygen. Liquid oxygen containers must be certified by
Underwriters Laboratory (UL) or other approved testing laboratories for
compliance with NFPA 50 requirements. The facility is responsible for defining
all potential hazards both graphically and verbally to all persons involved in the
use of liquid oxygen and ensuring the liquid oxygen provider does also.
j. Portable fire extinguishers. Portable fire extinguishers must be provided and maintained
to comply with the provisions of NFPA 10. For extinguisher types (A, B, C, and K), the
facility must comply with location, spacing, mounting heights, monthly inspections by
staff, yearly inspections by a licensed agent, including any necessary servicing, and
hydrostatic testing as recommended by the manufacturer.
1. Extinguishers in resident corridors must be spaced so that travel distance is not
more than 75 feet. The minimum size of extinguishers must be either 1-A for
water type or 2-A 5-BC type. Actual sizes must meet NFPA 10 requirements for
maximum floor area per unit covered. In large facilities, at least one portable
Underwriters Laboratory (U.L.) or factory mutual (F.M.)-approved 20-B:C dry
chemical fire extinguisher, rechargeable type, is required in each laundry, kitchen
and walk-in mechanical room.
2. Extinguishers must be installed on supplied hangers or brackets or be mounted in
cabinets approved by DADS.
3. Extinguishers must be surface wall-mounted or recessed in cabinets where they
are not subject to physical damage or dislodgement.
4. Extinguishers having a gross weight not exceeding 40 pounds must be installed so
that the top of the extinguisher is not more than five feet above the floor.
Extinguishers with a gross weight greater than 40 pounds must be installed so the
top of the extinguisher is not more than 3½ feet above the floor. The clearance
between the bottom of the extinguisher and the floor must not be less than four
5. Portable extinguishers provided in hazardous rooms must be located as close as
possible to the exit door opening and on the latch or knob side.
6. Staff must be appropriately trained in the use of each type of extinguisher in the
7. Regular monthly inspections or “quick checks” must be made by facility
representatives to assure that extinguishers are in the proper location, condition,
and working order. Annual maintenance or “thorough checks” must be
accomplished in accordance with NFPA 10 by competent personnel licensed or
certified to perform servicing by the State Fire Marshal. Unserviceable
extinguishers must be replaced.
k. Waste and storage containers.
1. Metal waste baskets of substantial gauge or any U.L. or F.M. approved containers
must be provided in facilities in all areas where smoking is permitted.
2. Garbage, waste, or trash containers provided for kitchens, janitor closets,
laundries, mechanical or boiler rooms, general storage, and similar places must be
made of metal or any U.L. or F.M. approved material with a close fitting cover.
Disposable plastic liners may be used in these containers for sanitation.
l. Accessibility provisions. The physical plant of facilities housing residents with physical
disabilities or mobility impairments must comply with applicable federal, state and local
requirements for persons with disabilities.
m. Resident accommodations.
1. Resident bedrooms.
A. Bedroom usable floor space for Type A facilities must not be less than 80
square feet for a one-bed room and not less than 60 square feet per bed for
a multiple bed room. A bedroom must be not less than eight feet in the
smallest dimension, unless specifically approved otherwise by DADS. A
bedroom for a person with a physical disability or mobility impairment
must meet accessibility standards for access around the bed or beds, which
is a minimum of 3′-0″ clear width for access aisles.
B. Bedroom usable floor space for Type B facilities must be not less than 100
square feet per bed for a single-bed room and not less than 80 square feet
per bed for a multiple-bed room. A bedroom for a person with a physical
disability or mobility impairment must meet accessibility standards for
access around the bed or beds, which is a minimum of 3′-0″ clear width for
access aisles. A bedroom must not be less than ten feet in the smallest
dimension unless specifically approved by DADS.
C. In facilities that have living units consisting of separate living spaces,
dining spaces, and bedrooms, 10% of the required bedroom square footage
may be included as part of the living and dining space.
D. A facility must have no more than 50 percent of its beds in bedrooms of
three or more beds. A bedroom must have no more than four beds.
E. Each bedroom must have at least one operable window with outside
exposure. The window sill must be no higher than 44″ from the floor and
must be at or above grade level. The window must be operable from the
inside, without the use of tools or special devices, and provide an operable
section with a clear opening of not less than 5.7 square feet with a
minimum width of 20″ x 41.2″ high and minimum height of 24″ x 34.2″
wide. Windows required for evacuation must not be blocked by bars,
shrubs, or any obstacle that would impede evacuation. Exceptions are as
i. In large Type B facilities and other facilities protected throughout
by an approved automatic sprinkler system, the window opening
size may be smaller than the minimum size listed in this
subparagraph but must permit the venting of products of
combustion in compliance with the Life Safety Code for
Healthcare Occupancy. The total window area in a bedroom must
not be less than 8 percent of the required bedroom size.
ii. In existing buildings, if the window is not required for the
secondary means of escape, the window size and sill height
requirements do not apply if the windows meet the requirements of
the local building code.
F. In the event the resident does not provide his or her own furnishings, the
facility must provide for each resident a bed with mattress, chair, table or
dresser, and enclosed closet space for clothing and personal belongings.
Drawer space must be provided. Furnishings provided by the facility must
be maintained in good repair.
G. All resident rooms must open upon an exit, corridor, living area, or public
area and must be arranged for convenient resident access to dining and
recreation areas.
H. A staff or attendant area must be provided on each floor or in each
separate building. The area must consist of a desk or writing surface and
telephone. An exception is that Type A facilities, two-story or less in
height, with separate buildings grouped together, and connected by
covered walks, need not have staff or attendant areas on each floor or in
each building, provided that the areas are not more than 200 feet walking
distance from the furthest resident living unit. The areas must have a
communication system and fire alarm annunciation indicating the units
I. Facilities which consist of two or more floors or separate buildings must
have a communication system from each resident living unit to a central
staff location. This communication system may be a direct telephone,
nurse call, or intercom.
2. Resident toilet and bathing facilities.
A. All bedrooms must be served by separate private, connecting, or general
toilet rooms for each sex if the facility houses both sexes. General toilet
room or bathing room must be accessible from a corridor or public space.
A lavatory must be readily accessible to each water closet. At least one
water closet, lavatory, and bathing unit must be provided on each sleeping
floor accessible to residents of that floor.
B. One water closet and one lavatory for each six occupants or fraction
thereof including a portion less than six is required. One tub or shower for
each ten occupants or fraction thereof is required.
C. Privacy partitions or curtains must be provided at water closets and
bathing units in rooms for multi-resident use.
D. Tubs and showers must have non-slip bottoms or floor surfaces, either
built-in or applied to the surface.
E. Resident-use hot water for lavatories and bathing units will be maintained
between 100 degrees Fahrenheit and 120 degrees Fahrenheit.
F. Towels, soap, and toilet tissue must be available at all times for individual
resident use.
3. Resident living areas.
A. Social-diversional spaces must be provided and have appropriate furniture.
Examples of social-diversional spaces include living rooms, day rooms,
lounges, dens, game rooms, and sunrooms. A minimum of 120 square feet
must be provided in at least one space regardless of number of residents.
This space must have exterior windows providing a view of the outside.
B. The total space requirement for social-diversional areas must be provided
on a sliding scale as follows:
No. of Beds Area Per Bed Minimum
4-16 15 sq. feet (min. 120 sq. ft.)
17-39 13 sq. feet
40-59 12 sq. feet
60+ 10 sq. feet
C. For calculation purposes, DADS deducts a pathway equal to the corridor width when a
corridor is required through a living or dining area to access an exit. The exit pathways
must be kept clear of obstructions.
4. Resident dining areas.
A. A dining area must be provided and have appropriate furnishings. A minimum of
120 square feet must be provided in at least one space, regardless of number of
residents. This space must have exterior windows providing a view of the outside.
B. Access to a dining area from the resident living units or bedrooms must be

5. Storage areas. The facility must provide sufficient separate storage spaces or areas for the
following: 79
A. administration for records and office supplies;
B. locked areas for medications and medical supplies. Poisons must be stored in a
locked area and separate from all medications and preparation;
C. equipment supplied by the facility for resident needs including wheelchairs,
walkers, beds, and mattresses;
D. cleaning supplies including janitorial needs;
E. food storage;
F. clean linens and towels if furnished by the facility;
G. lawn and maintenance equipment, if needed;
H. janitor closets with deep sink and hot and cold water for large facilities; and
I. soiled linen storage or holding room if the facility furnishes linen.
6. Kitchen.
A. The facility must have a kitchen or dietary area to meet the general foodservice
needs of the residents. It must include provisions for the storage, refrigeration,
preparation, and serving of food, dish and utensil cleaning, and refuse storage and
removal. Exception: Food may be prepared off-site or in a separate building
provided that the food is served at the proper temperature and transported in a
sanitary manner.
B. Kitchens for facilities serving 16 or fewer non-employees per meal on a routine
basis that have residential ranges may have residential range hoods, if the range
hoods meet the requirements of the local building code.
C. Kitchens for facilities serving 17 or more non-employees per meal on a routine
basis must be designed as follows:
i. Kitchens are evaluated on the basis of their performance in the sanitary
and efficient preparation and serving of meals to residents and compliance
with requirements for dietary service in §92.41(m)(18) of this chapter
(relating to Standards for Type A and Type B Assisted Living Facilities).
I. A facility must consider the type of meals served, the overall
building design, the food service equipment, arrangement, and the
work flow involved in the preparation and delivery of food.
II. Plans must include a detailed kitchen layout designed by a
registered or licensed dietitian or architect with knowledge of the
design of food service operations.
ii. Kitchens must be designed so that room temperature, at peak load or in the
summer, must not exceed 85 degrees Fahrenheit measured over the room
at the five foot level. The amount of supply air must take into account the
large quantities of air that may be exhausted at the range hood and
dishwashing area.
iii. Facilities for washing and sanitizing dishes and cooking utensils must be
provided. The kitchen must contain a multi-compartment pot sink large
enough to immerse pots and pans, and a mechanical dishwasher for
washing and sanitizing dishes. Separation of soiled and clean dish areas
must be maintained, including air flow.
iv. A food preparation sink must be provided. It must be separate from the pot
and hand sinks.
v. A supply of hot and cold water must be provided. Hot water for sanitizing
purposes must be 180 degrees Fahrenheit or the manufacturer’s suggested
temperature for chemical sanitizers.
vi. The kitchen must be provided with a hand-washing lavatory in the food
preparation area with hot and cold water, soap, towel dispenser, and waste
receptacle. The dish room area must have ready access to a hand washing
vii. Staff restroom facilities with lavatory must be directly accessible to
kitchen staff without traversing resident use areas. The rest room must not
open directly into the kitchen, but must open into a vestibule. An
exception may exist in an existing facility if the staff restroom is located
outside of the kitchen area.
viii. Janitorial facilities must be provided exclusively for the kitchen and must
be located in the kitchen area. An exception may occur if a janitorial closet
in an existing facility is located outside of the kitchen and if sanitary
procedures are used to reduce the possibility of cross-contamination.
ix. Non-absorbent smooth finishes or surfaces must be used on kitchen floors,
walls and ceilings. Surfaces must be capable of being routinely cleaned
and sanitized to maintain a healthful environment. Counter and cabinet
surfaces, inside and outside, must also have smooth, cleanable, non-porous
x. Doors between kitchen and dining or serving areas must have ¼-inch fixed
safety glass or a fire related glazing view panel mounted in a steel frame.
xi. A garbage can or cart washing area with drain and hot water must be
provided either on the interior or exterior of the facility.
xii. Floor drains must be provided in the kitchen and dishwashing areas.
Exception: Floor drains are not required in existing facilities provided the
floors are kept clean.
xiii. A commercial range must be provided and equipped with a commercial
range hood and exhaust designed and installed in accordance with NFPA
xiv. Grease traps must be provided as required by local authorities.
D. Food storage areas for large facilities must be as follows.
i. Food storage areas must provide for storage of a four-day minimum
supply of non-perishable foods at all times.
ii. Shelves must be adjustable wire type. An exception may occur if an
existing facility uses wood shelves and keeps the shelves sealed and clean.
iii. Walls and floors must have a non-absorbent finish to provide a cleanable
iv. Food must not be stored on the floor. Dollies, racks, pallets, or wheeled
containers may be used to elevate foods not stored on shelving.
v. Dry foods storage must have an effective venting system to provide for
positive air circulation.
vi. The maximum room temperature for food storage must not exceed 85
degrees Fahrenheit at any time. The measurement must be taken at the
highest food storage level, but not less than five feet from the floor.
vii. Food storage areas may be located away from the food preparation area as
long as there is space adjacent to the kitchen for necessary daily usage.
E. Auxiliary serving kitchens that are not contiguous to a food preparation or serving
area must be designed as follows.
i. Where service areas other than the kitchen are used to dispense foods,
these areas must be designated as food service areas and contain
equipment for maintaining required food temperatures while serving.
ii. Separate food service areas must have hand washing facilities as part of
the food service area.
iii. Finishes of all surfaces must be the same as those required for food and
nutrition services or comparable areas.
7. Laundry and linen services.
A. A large assisted living facility that co-mingles and processes laundry on-site in a
central location must comply with the following.
i. The laundry must be separated and provided with sprinkler protection if
the laundry area is located in the main building. Separation must consist of
a one-hour fire rated partition carried to the underside of the floor or roof
deck above. Access doors must be from the exterior or interior nonresident use areas including a small vestibule or service corridor.
ii. The laundry must be provided with the following physical features:
I. a soiled linen receiving, holding, and sorting room with a floor
drain and forced exhaust to the exterior which must operate at all
times when soiled linen is held in this area and may be combined
with the washer section;
II. a general laundry work area that is separated by partitioning a
washer section and a dryer section;
III. a storage area for laundry supplies;
IV. a folding area;
V. adequate air supply and ventilation for staff comfort without
having to rely on opening a door that is part of the fire wall
separation; and
VI. provisions to exhaust heat from dryers and to separate dryer makeup air from the habitable work areas of the laundry.
B. If linen is processed off the site, the following must be provided on the premises:
i. a soiled linen holding room with adequate forced exhaust ducted to the
exterior; and
ii. a clean linen receiving, holding, inspection, sorting or folding, and storage
C. Resident-use laundry, if provided, must utilize residential type washers and
dryers. If more than three washers and three dryers are located in one space, the
area must be separated by a one-hour fire rated barrier or have sprinkler