State Required Annual Building Inspections—Title 19

State laws have been created for the purpose of establishing minimum standards for the prevention of fire and for the protection of life and property against fire, explosion, and panic. UCSF’s Fire Prevention Program operates under an agreement with Office of the State Fire Marshal which authorizes our responsibility to conduct building inspections of state-owned or state-leased buildings. Title 19 building inspections are generally conducted annually to determine compliance with California Code of Regulations (CCR) Title 19.

What is the Title 19 inspection process?

During the Title 19 building inspection, UCSF Fire Prevention will identify infrastructure and behavioral violations that impact fire and life safety. Report summaries are sent to support services teams and, as applicable, local department leaders for review and immediate correction, or to develop an executable plan for correction within 30 days for any identified deficiencies. Local department leaders must email [email protected] and include their building address, floor, and/or room to advise correction of deficiencies.

How you can help prepare for your upcoming inspection

Behavioral fire code violations are life safety hazards that are created by occupants in the building, putting everyone at risk. Learn to recognize these life safety hazards and keep everyone safe. Below are the top 6 behavioral fire hazards at UCSF and how to correct them.

Review the GENERAL FIRE SAFETY updates to prepare for your inspection and address the top behavioral fire hazards

Corridors, Stairways, and Exit Paths

Obstructed exit corridors and stairways a prevent rapid evacuation and firefighter response. Clear exiting offers safe and smoke free passage out of the building. Corridors and stairways must remain clear at all times and contain no storage.

Check for and correct:

  • Corridors obstructed by supplies and equipment
  • Unapproved furniture placement (tables/chairs)
  • Recycling bins left in exit corridor
  • Unclaimed mail and parcel deliveries
  • Stairways used to store supplies

For more info, see Corridors and Exit Paths 101  AND  Stairways 101

Fire Doors

Fire doors save lives by reducing the spread of smoke and fire. Fire rated doors must close and latch. Only electric hold-open devices tied into the building fire alarm are permitted.

Check for and correct:

  • Wedges, hooks, or other means of preventing fire doors from closing
  • Taping over door latches or strike plates
  • Propping doors open with equipment, etc

For more info, see Fire Doors 101

Compressed gas cylinder storage/use

Compressed gases can be toxic, flammable, oxidizing, corrosive, or inert. Leaks or ruptures can quickly displace air in a large area and create an oxygen-deficient atmosphere. Toxic gases can create poison atmospheres, and flammable or reactive gases can result in fire and exploding cylinders. The physical weight of a cylinders falling over can cause severe bodily injuries. Cylinders can become missiles if the cylinder valve breaks off when falling!

Check for and correct:

  • Unsecured gas cylinders
  • Cylinder caps are in place when not in use
  • Small cylinders must be in approved storage racks or transport carts
  • Large compressed gas cylinders
    — require double chains/restraints
    — no more than three cylinders per bundle on wall struts

For more info, see Compressed Gas Cylinders Use, Storage, and Transport

Fire Sprinklers, Storage and Ceiling Clearance

Fire sprinklers put out fires effectively only when they are not obstructed by storage or fixtures attached to the building.

Check for and correct:

  • 18 inches of clearance below sprinkler head, no obstructions
  • Nothing is hanging from sprinkler head or sprinkler piping
  • Areas in buildings without fire sprinklers require 24 inches of clearance from ceilings

For more info, see Fire Sprinklers, Storage and Ceiling Clearance 101

Electrical Safety

Extension cords and power strips being used in an unsafe manner are a leading cause of fires.

Check for and correct:

  • Maintain 36 inches clearance in front of electrical panels, floor to ceiling
  • No Daisy Chains: Extension cords or power strips must be plugged directly into an electrical wall outlet, not into each other!
  • Extension cords must not go through walls or under doors or rugs and floor mats
  • Large amperage appliances and heat producing appliances must be plugged directly into wall outlets
  • Fire Preventions discourages use of personal space heaters

For more info, see Electrical Safety (1 page) AND Comprehensive Electrical Safety (3 pages)

Housekeeping: Overcrowding, combustible materials, equipment and supplies not properly managed.

Congested working areas limit access for regular cleaning and decluttering. Poor housekeeping also adds unnecessary fire fuel loads into the building. Good housekeeping will improve fire safety as well as the general health and safety of the department and UCSF.

Check for and correct:

  • Storage blocking access to firefighting equipment and electrical panels
  • Storage which can affect the safe evacuation of occupants
  • Hazardous conditions (i.e. electrical, daisy chaining of surge protectors) next to or under stored materials
  • Unstable stacks of materials

For more info, see Fire Prevention 101  AND  Hoarding and Fire: Resources to Declutter

How do I review the Title 19 inspection report for my building and communicate resolution of deficiencies?

Access Title 19 reports here via Building Inspection Reports & Plans of Correction. Then follow these steps:

  1. Navigate to the “Behavioral Category” within the Title 19 Report; you can search (Ctrl + F) the report for room locations to see violations needing correction and to find photos for clarification.
  2. Focus on deficiencies with a Non-Compliant status (red side-bar).
  3. Locate deficiencies based on the room location/area cited.
  4. Correct deficiencies (e.g., discuss at staff meeting, remove items in egress path, discard or relocate combustible materials to an appropriate storage room, etc.) within your department scope or engage necessary support service using like MCSS Help Desk (UCSF Health) or Campus Life Services Facilities.
  5. Email [email protected] with "Title 19 correction" in the subject line, the building address, floor, or room number/area description to advise correction of deficiencies.

Deficiencies not addressed in the expected timeframe will be re-cited by Fire Prevention and an escalation report sent to the UCSF Health Chief Operating Officer (COO) and Safety Officer or appropriate Campus Department Chair!

Once deficiencies are resolved, please email [email protected] with "Title 19 correction" in the subject line, the building address, floor, or room number/area description to advise correction of deficiencies.

Direct any questions about the Title 19 Building Inspection process by email to [email protected] or dial (415) 476-1300.


EHS Categories

Fire and Life Safety