Administrative Frequently Asked Questions

Administrative 2007 California Administrative Code#

1. Does OSHPD provide a list of governing codes that pertain to health facilities?#

Yes. Current and previous governing codes are listed in Code Application Notice (CAN) 1-0.

2. If a project is submitted under the applicable governing codes but a newer edition of a code is available, can we pick and choose portions of a code?#

No. The project must comply with all governing codes in effect when a Preliminary or Final Application for Plan Review is submitted to the Office. Please refer to CAN 1-0.

3. What OSHPD procedure should be used when an architect or engineer disagrees with an OSHPD plan review staff member or an OSHPD field staff member on a code interpretation?#

OSHPD′s clients should use the Comment and Process Review (CPR) procedure to resolve disagreements involving code interpretation issues or OSHPD processes and procedures.

4. What is required of a Skilled Nursing Facility (SNF) for the temporary voluntary conversion of all or a portion of its licensed bed capacity for the purpose of using the facility as a licensed Mental Health Rehabilitation Center (MHRC)?#

In 2004, legislation was passed that explains the requirements. Please refer to Section 1271.15 of the Health and Safety Code.

5. Are any construction projects for hospitals and skilled nursing facilities exempt from the OSHPD plan review process?#

Legislation has been passed which provides that, under specific circumstances, a hospital or skilled nursing facility project may be exempt from the OSHPD plan review process. The enactment of Assembly Bill 2632 (Chapter 453, Statutes of 2004) added Health and Safety Code Section 129875.1 which allows certain maintenance and repair work projects for hospitals and skilled nursing facilities to be exempt from plan review, if specific criteria is met. AB 2632 provisions apply to such projects in “single-story” buildings.

The enactment of Senate Bill 1838 (Chapter 693, Statutes of 2006) added Health and Safety Code 129880 which allows hospital, skilled nursing facility and intermediate care facility construction or alteration projects costing less than $50,000 to be exempt from the OSHPD plan review process, if specific criteria are met. OSHPD′s Policy Intent Notice (PIN) 36 outlines the process and procedures for submittal of such projects.

Although projects that meet the criteria for Health and Safety Code Section 129875.1 or 129880 are exempt from the OSHPD plan review process, they are not exempt from issuance of a building permit and construction observation by OSHPD.

OSHPD′s Field Reviewed Projects, Exempt Projects & Expedited Review Projects Manual (FREER Manual) provides a guide to help identify other types of projects that may be considered “exempt”. Projects that are identified as “exempt” will not require submittal of a building permit application, project plans or a fee. The project is not exempt from the OSHPD field observation necessary to assure code compliance.

6. Why does the application form for OSHPD plan review request the name of a “Facility Representative”?#

Upon the recommendation of the hospital industry, OSHPD requests that hospitals and skilled nursing facilities identify a “facility representative” who will receive copies of all project correspondence from OSHPD and who will be the contact person when discussion of plan review or construction issues is necessary. This provides facilities easier access to information about the review of their projects and reduces confusion regarding the status of the reviews. When projects are received by OSHPD, the name of the facility representative, if identified, is entered into the eServices Portal (eSP) database and this information is used for sending all correspondence to that individual. If this information is not provided, the “facility administrator” will receive copies of all correspondence.

7. Can a licensed specialty contractor prepare plans and specifications for a project consisting only of a fire sprinkler system?#

see Fire and Life Safety, General, Question 3

8. What are the stamping and signature requirements for a deferred submittal?#

Stamping and signature requirements must comply with California Administrative Code (CAC) Section 7-126.

9. Who is responsible for updating the Testing, Inspection, and Observation (TIO) Program for a specific project?#

The architect or engineer in responsible charge of the work must maintain the TIO Program, pursuant to CAC Section 7-141 (d).

10. Does OSHPD have a special form or letter for submitting an Alternate Method of Compliance (AMC) request?#

OSHPD prefers that AMC requests are submitted on the Alternate Method of Compliance Form (OSH-FD-126) available from the FDD Forms web page.

11. My plans have been stamped “approved” by OSHPD. However, during construction the OSHPD field staff has stated that the plans are not code compliant and has given verbal direction to make changes that deviate from the approved plans. What recourse, if any, do I have when this occurs?#

OSHPD has an internal process for resolving issues pertaining to the approved plans. Clients may contact the Regional Compliance Officer (RCO) to verify that the issue is being reviewed and resolved internally. Insofar as practical, the plans will stand as approved. However, issues involving life safety must be corrected or changed as necessary to the extent required to make the building and its occupants safe regardless of what is shown on the approved plans

If the client does not believe the issue has been resolved satisfactorily, they may use the Comment and Process Review (CPR) procedure to resolve disagreements involving code interpretation issues or OSHPD processes and procedures.

12. Does OSHPD have any concern over the process of Owner approval of Owner Vendor installations so long as they meet the Approved Contract Documents?#

Yes. The installation by vendors must be under the general responsibility of the General Contractor of Record or the Owner/Builder for the specific project under which it is being installed, or must be submitted as a separate project. Otherwise, the work is being performed without benefit of a building permit, verification of appropriately licensed contractor, and verification of the necessary Worker′s Compensation coverage.

13. Would OSHPD allow the contractor to hire the special inspector?#

No. Section 1707A.4 of the California Building Code (CBC) requires the owner to employ the special inspector(s).

14. Does OSHPD have requirements regarding the size of paper on which plans are submitted?#

Yes. CAC Section 7-113 states, “Plans/drawings size shall not exceed 36 X 48 inches, and bundled sets of plans/drawings shall not exceed 40 lbs. in weight.” In addition, CBC Appendix Chapter 1, Section 106.1.1 states, “Construction documents shall be of sufficient clarity to indicate the location, nature and extent of the work proposed and show in detail that it will conform to the provisions of this code and relevant laws, ordinances, rules and regulations, as determined by the building official.”

15. Are changes to plans required to be incorporated into the original plans?#

No. OSHPD does not have a policy that changes be incorporated into the original plans.

16. Does a design professional have to stamp/approve a small project if all work done is using pre-approved details?
Yes. The CAC requires plans for hospitals to be prepared by an appropriately California licensed professional. The pre-approved details have been prepared and stamped by a licensed professional. Therefore, these should not require restamping. However, someone must determine the applicability of the details to the project and prepare plans showing where the details apply, etc.

17. Can the Inspector of Record (IOR) daily report be electronic or does it have to be a hard copy?#

The regulations do not specify whether the IOR report has to be a hard copy. The report is required to be retained on the job site and made available to the OSHPD field staff, the architect or engineer in responsible change, or the owner upon request. The original field records must be turned over to the hospital governing authority upon completion of the project. Therefore, the owner may have a preference regarding the manner in which reports are made and maintained.

Regardless of the media or method of reporting used, the IOR must demonstrate, upon request by OSHPD field staff that their field records comply with the applicable regulations. If an electronic method is used, the IOR must have a manner in which the data is backed-up in the event of a hard disk crash, loss of computing equipment, etc.

18. There appears to be confusion regarding OSHPD′s jurisdiction as it relates to the hospital building site. If the local jurisdiction is responsible for parking, landscaping, drainage, site utilities, etc., how far does OSHPD′s jurisdiction extend beyond the building line? It was my understanding that OSHPD didn′t look at anything more than 5 feet outside of the building perimeter.#

It may be appropriate and necessary for OSHPD to review certain work extending beyond 5 feet from the building, such as the underground fire main, private utilities, slopes and grade pertaining to accessibility, proximity of adjacent structures for wall and opening protection requirements, fire department access, etc. Other work shown on drawings beyond the arbitrary 5 ft. dimension are clearly within the responsibility of the local jurisdiction, such as size and number of parking spaces, landscaping and other site development features, etc. The determining factor is whether the work in question affects the compliance of the hospital building with the California Building Standard Code requirements that are enforced by OSHPD.

19. Is it permissible to plot the OSHPD approval stamp for office reviews or field reviews on our drawings?#


20. What is the proper procedure for adding additional sheets to an approved set of construction documents?#

CAC Section 7-153(a) states, “Work shall be executed in substantial conformance with the construction documents approved by the Office. Changes in the work shall be made by addenda, change orders, or instruction bulletins approved by the Office.” Changes or alternations of the approved construction documents prior to awarding a construction contract shall be made by means of addendum.

Changes or alterations of the approved construction documents after a contract or similar instrument of agreement has been awarded shall be made by means of change orders.

NOTE: Added scope to a project may constitute a new project. If there is any question, contact the Plan Review Supervisor for clarification prior to submitting the work to OSHPD.

21. When is it appropriate to submit changes in the form of an Instruction Bulletin (IB) rather than a Change Order (CO)?#

In accordance with CAC Section 7-153 (a) 3, Instruction Bulletins are only permitted to be used to prevent undue delay in construction as determined by the OSHPD Field Staff. If it is determined that the change does not adequately demonstrate an impact to the construction schedule or it does not materially alter the work to be performed, OSHPD may reject the IB. Change that does not constitute an undue delay in construction must be submitted to OSHPD in the form of a change order. All IB′s must be converted to a change order within 30 days of approval. Please see CAN 1-7-153 (a) for additional information.

22. If Post Approval Documents are submitted simultaneously or closely following each other, should the information from IB#1 (now at OSHPD but not approved yet) be clouded on IB#2 (if on the same sheet) or should only the OSHPD approved changes be shown?#

The clouded changes from IB#1 should be shown on IB#2. Clearly note on IB#2 that those IB#1 changes have not yet been approved.

23. Are wet signatures always required on documents submitted to OSHPD?#

In CAC Section 7-111, the definition of “SIGN, SIGNED, SIGNATURE, and SIGNATURES” means to affix an individual′s signature by manual, electronic, or mechanical methods. Manual method includes, but is not limited to, a pen and ink signature. Electronic method includes, but is not limited to, scanned signature images embedded in construction documents, faxes, or other electronic document files. Mechanical method includes, but is not limited to, rubber stamp signature.

24. Does the OSHPD Anchorage Pre-approval Program approve and list building materials, for example: fire-resistive systems and components?#

No. The OSHPD Anchorage Pre-approval Program is not a building materials listing program. The program is limited to approvals of anchorage and bracing systems only. OSHPD′s accepatance of fire-resistive systems and components is based on Chapter 7 of the CBC. Tested and listed systems are acceptable. CAN 2-703.3 establishes guidelines for the preparation, submittal, and review of Engineering Judgements.

OSHPD does not provide endorsements regarding the acceptance of suitability of any manufacture′s product.

Architectural 2007 California Building Code (CBC)#

1. Does OSHPD allow the use of modular toilet/sink combination units in health facilities?#

Yes, but only in Intensive Care Units. Section 1224.29.1.4 allows the use of modular toilet/sink combination units in Intensive Care Units. The 2007 California Building Code (CBC) states that toilet fixture must be completely contained within cabinetry when not in use and exhaust ventilation requirements must comply with the 2007 California Mechanical Code (CMC).

2. What are the requirements for Electronic Medical Records (EMR) in health care facilities?#

Section 1224.21.2 requires that hospitals provide a health record service that contains a work area for sorting and recording either paper or electronic media records and a storage area for either paper or electronic media records. Both the work area and the storage area must be indicated on the construction plans for OSHPD review.

Active and inactive medical records may be located off-site if approved by the California Department of Public Health. Medical record availability requirements are found in Section 70751(f) of Title 22, California Code of Regulations which states: “Medical records shall be filed in an easily accessible manner in the hospital or in an approved medical record storage facility off the hospital premises”. The California Department of Public Health, Licensing and Certification (L&C) is authorized to approve the “off-site” storage of medical records, whether the records are active or inactive. For new construction or a relevant remodeling project, OSHPD must receive a copy of the L&C approval letter if the electrical medical records system is “off the hospital premises”. If the EMR computer server is located in the hospital, OSHPD must review the server location, anchorage, fire and life safety requirements, mechanical requirements, and electrical requirements.

Electrical 2007 California Electrical Code (CEC)#

1. When is fire-resistant construction required for an electrical room or a transformer room?#

Article 450.21(B) states that individual dry-type transformers of more than 112 ½ kVA installed indoors must be installed in a transformer room of fire-resistant construction. Unless otherwise specified in this article, the term fire-resistant means construction having a minimum fire rating of one hour. Please refer to Article 450.21(B) for exceptions.

2. Are electrical rooms considered storage rooms in Table 508.2 of the 2007 California Building Code (CBC)?#

Electrical rooms are not storage rooms; therefore, they are not required to meet the “storage rooms” requirements of Table 508.2 of the CBC.

3. Is fire alarm wiring required to be installed in conduit?#

In general, the fire alarm wiring must be installed in conduit; however, exceptions are described in Articles 760.30 and 760.52.

4. Are wireless nurse call systems allowed in health facilities?#

Articles 517.42 and 517.44 allow wireless nurse call systems in skilled nursing facilities and intermediate care facilities. Wireless nurse call systems are not allowed in general acute-care hospitals. The system must comply with ANSI/UL 1069, Standard for Hospital Signaling and Nurse Call Equipment. In addition, all wireless nurse call systems must comply with Article 517.123.