EFTA00036924.pdf

ACA WALK-THROUGH DISCUSSION ISSUES
SAFETY AND EMERGENCY PROCEDURES
ALL SUPERVISORS: The following questions may be asked of employees when touring the
institution:
1. What are the evacuation routes for this area? Are they posted? Where?
2. How often are fire drills conducted? Have you participated in fire drills? What are the
procedures for evacuation and obtaining emergency keys?
3. Have you received training on the use of fire extinguishers and SCBA?
4. Where are the fire extinguishers and SCBA located in this area?
5. If you are in another part of the facility, could you find the fire extinguishers?
6. What are the procedures for the storage and control of toxic, caustic, and flammable
materials and cleaning supplies?
7. Where are MSDS books located? When and how would you use these?
8. What is the tool control and key control plan?
9. How many keys do you have on your key ring and do they all work?
10. Is there a duplicate set of keys for your area and are they checked frequently?
I I. Where are the one way mouth masks (CPR) located?
12. Have you participated in an emergency preparedness drill?
13. What are the procedures for a blood spill?
14. How many official counts are conducted daily?
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Inmate Admission and Orientation
ISM Supervisors and staff should be able to address the following questions:
I. What is issued to an inmate upon arrival at the institution?
2. Do medical personnel sec the inmate upon arrival? Do they receive a medical screening?
3. What if the inmate does not speak English?
4. What is the procedure for checking personal property? Where is it stored?
5. How soon does the A&O committee see the inmate after arrival?
6. Where are your chemicals stored? How are they dispensed? Are inventories kept on all
chemicals? Verify bin cards.
7. Discuss fire/emergency issues.
8. Arc sack lunches kept in the area? If so, are temperature logs maintained for the
refrigerator?
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Unit Management
All Unit staff should be able to address the following:
1. How soon after arrival does the inmate complete A&O?
2. How soon after arrival is the inmate given orientation to the facility and unit?
3. How soon is the inmate assigned to a program?
4. Who has access to inmate files? Where are they kept?
5. Do you have group counseling available on the unit?
6. Is there a pre-release program?
7. How frequently are inmates reviewed for re-classification?
8. How does the inmate access counseling regarding the following:
a. Unit
b. Religious
c. Psychological
d. Substance abuse
9. Discuss fire/emergency procedures.
10. Are there any unique programs or services available in your unit?
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Inmate Rights
The following areas should be discussed explaining the facility's full compliance with ACA
Standards:
1. Discuss how BOP directives give an inmate access to the courts through certain rights
such as:
a. Legal visits from attorneys
b. Correspondence privileges including mail for indigent inmates.
c. Access to law library that provides:
1) Legal research materials
2) Reasonable access to typewriters for the preparation of legal documents
2. Discuss the presence of private interview rooms in the visiting area that facilitate
attorney/client confidentiality.
3. Discuss inmate access to telephones and how an inmate may call his attorney.
4. Discuss how inmates have the right to refuse to participate in any rehabilitation program
except:
a. Adult Basic Education
b. GED
c. Court ordered programs
5. Discuss personal grooming freedom and how the facility has written guidelines that
prohibit only conditions effecting facility safety, security, identification and hygiene
considerations.
6. Discuss inmate access to the media via correspondence and/or telephone. Mention how
requests for interviews with inmates from the media must be in writing and how an
inmate must sign a consent form before interviews are granted.
7. Discuss the BOP's and facility's commitment to non-discrimination in program
considerations, work assignments, etc.
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8. Discuss BOP directives and facility policy and procedures and how they prohibit:
a. Cruel and unusual punishment
b. Harassment
c. Property damage
9. Discuss the grievance procedure and appeal process.
10. Discuss the presence of written guidelines regarding cell searches and pat down and strip
searches.
11. Discuss the fact that food in not used as a reward or a punishment.
12. Discuss Use of Force policy.
13. Discuss weekly inspection procedures.
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Inmate Disciplinary Procedures
Areas of critical concern to auditors regarding Accreditation Standards, State Law, BOP
directives, and facility policy and procedure should be mentioned showing our full compliance.
I. Discuss how the facility operates using Administrative Regulations and that all conduct
reports reflect alleged violations to specific rule violations.
2. Discuss how the facility has certain facility-specific posted rules such as Visiting Room
rules and Procedures and when a violation occurs, the inmate is cited for violation of
BOP standard "disobeying a direct order" or "failing to follow posted rules and
regulations."
3. Discuss how the Rules of Conduct are issued to all inmates, and when they are issued.
Also note that if a lanuage or literacy barrier exists, the BOP is prepared to provide the
necessary translation.
4. Discuss the inmate disciplinary process, beginning with the rules of procedures:
Disciplinary Hearing Officer (DHO), and include the Unit Disciplinary Committee
(UDC).
5. Discuss the availability of the above referenced material , where it is located and how
frequently the inmates can access the information.
6. Discuss employee training in informally resolving minor rule infractions, writing reports
and properly documenting more serious inmate misbehavior in a formal manner.
7. Discuss time limitations in the due process of disciplinary procedures:
a. Within 24 hours: when an alleged rule violation is reported an appropriatc
investigation is begun
b. Within 72 hours: a review by the appropriate authority of inmates placed in
immediate segregation to protect the inmate or others
8. Discuss Special Housing Unit (SHU) placement reasons, very serious violations, that the
hearing is conducted by a DHO, review of status, and privileges and programming.
9. Discuss the grievance procedure and appeal process.
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Housing Units
1. Discuss fire/safety and evacuation. When was the last fire drill conducted?
2. What is the procedure for an inmate to file a grievance?
3. What is the role of the institution Safety Manager?
4. What are the guidelines for conducting cell searches? Who can authorize a search? What
is a pat down or strip search? When can a strip search be conducted? Who can conduct?
5. Do you have post orders for your post? Are they signed?
6. How do you control caustics, toxics, and fiammables? How are cleaning supplies
distributed and controlled?
7. Discuss meal procedures.
8. Explain the following:
a. Shower schedule
b. Legal mail
c. Visits
d. Commissary
e. Laundry procedures
f. Law library access
g. Access to leisure library
h. Regular mail and packages
i. Sick call
j. Housekeeping procedures/schedules
9. How many inmates are housed per unit? How many showers are available?
10. Verify there are an adequate number of writing surfaces available in the day room areas.
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I I What chemicals are in your area and how are they issued to inmates?
12. How often are inspections conducted by the Safety Officer?
13. How often are sanitation inspections conducted and by whom?
14. Where are your post orders kept and have they been signed?
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Special Housing Unit (SHUN
1. Explain recreation and shower schedules. Where do inmates recreate in inclement
weather?
2. Is personal property allowed? Where is it stored? Are items cleaned prior to storage?
What if there is blood on clothing items?
3. Does the inmate have access to phones calls? How frequently?
4. Does the inmate have access to visiting? How frequently? Is this non-contact visiting?
5. How frequently are the inmates seen by Correctional Counselors, Chaplains, Medical, and
Executive staff?
6. Explain laundry exchange procedures.
7. What are the procedures for legal mail, regular mail, law library, and leisure library?
8. Discuss fire/safety issues. Explain fire drill procedures.
9. What log books are maintained? What is entered in these log books?
10. How frequently do you make rounds?
11. How are meals heated? Do you take the temperature prior to serving? Are inmates
served the same quantity and quality meal as the general population? Are temperature
logs maintained on the refrigerators?
12. How are alternative meals (sack lunches) approved? How long can sack lunches be
given?
13. Explain the Use of Force procedures. What are the procedures for the Use of Restraints?
14. How soon is Health Services notified when an inmate is transferred to SHU? What are
the procedures?
15. Explain tool and key control.
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Rear Sallvport
1. Explain receiving procedures.
2. Explain vehicle processing procedures.
3. Explain gate pass procedures. Are inmates strip searched prior to coming back into the
compound? Have you been trained to conduct strip searches?
4. What logs are maintained?
5. Discuss chemical control.
6. Discuss fire/safety procedures.
7. Do you have post orders? Are they signed?
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Laundry
1. What type of clothes are issued? In what quantities? What type of inventory is
maintained? Explain change of season procedures.
2. How often can inmates exchange clothing? Linens?
3. Explain the laundry procedures.
4. Who washes personal clothing?
5. Explain chemical control. Verify inventory with bin cards. Are chemicals stored
properly? Is PPE available? Where is the closest eyewash station?
6. Explain tool control.
7. Discuss fire/safety procedures.
8. Ensure fire exits and eyewash stations are not blocked by laundry carts.
9. Is bleach used? If so, how is it dispensed?
10. How are leather shoes disinfected?
11. Are sewing needles controlled and inventoried?
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Warehouse
1. What are the inventory procedures? How frequently are inventories conducted?
2. Is there an ample supply of personal hygiene items on inventory?
3. What are your receiving/distribution procedures?
4. Discuss fire/safety issues.
5. How frequently is garbage removed?
6. How often are pest control measures carried out?
7. Discuss controls of caustics, toxcis, and flammables. Verify bin cards. Verify chemicals
are stored properly.
8. Discuss security measures in the area.
9. Are temperature logs maintained on freezers/coolers? What are the proper temperatures?
10. Arc aisles marked appropriately and is there space between the racks and walls to visually
inspect for pests?
11. Are the means of egress marked and clear? Verify there are not "dead end" rows.
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Commissary
1. How often do inmates have access to the commissary? What restrictions are there on
buys? What are the procedures for special purchases?
2. What is the procedure for an inmate to make a purchase?
3. Discuss inventory control procedures.
4. What is the maximum dollar amount an inmate can spend?
5. Verify hair care products do not have warning or toxic labels on them. Check nail polish
and nail polish remover at female institutions.
6. Do you maintain temperature logs for freezers/coolers? If not, how do you ensure the
proper temperatures are maintained?
7. What are the commissary accounting procedures? What are funds generated from
commissary sales used for?
8. Is there a committee to review products for sale? Who is on the committee?
9. What are the procedures for assessing products - are inmates allowed to request items for
purchase?
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Health Services
1. Discuss the FOUR minute response. Who is trained? Who responds to medical
emergencies? What type of equipment is taken on response? Are drills conducted? How
frequently? Who has responsibility for the control and inventory of emergency carts?
How often are items inventoried?
2. Who maintains medical records? Who can access the files? What is the procedure for
sharing information with non healthcare providers?
3. Discuss pharmacy control of medications and narcotics. How is pill line conducted?
Look at sanitation of the pharmacy. Ensure the floor is clear of pills. How often are
inventories conducted? Who has access (keys) to the pharmacy? Explain procedures for
access after hours.
4. How often do you conduct sick call? Are inmates triaged?
5. Discuss chemical control. Verify chemicals are stored properly and inventory is correct.
6. Check x-ray room to ensure developer and fixer are being controlled and inventoried.
7. What is the policy on used needles and hazardous waste handling. How frequently is
hazardous waste disposed of? Is the biohazard waste storage room ventilated to the
outside?
8. Do inmates assist in medical/dental procedures? How are they trained?
9. What do you look for during the medical intake screening process? How soon after an
inmate arrives at the institution do you conduct a full health appraisal?
10. How are emergencies (medical, dental, and mental health) handled during non-duty
hours? Do you have a written plan for responding to medical emergencies?
11. Do all health care providers have a current license? Are they on file and current?
12. Discuss fire/safety concerns. How often are fire drills conducted? Every shift?
13. Verify that food is not being stored in refrigerators marked "Do not store food or food
products."
14. What types of services/clinics arc offered?
15. What outside hospital services the institution? How far away is the nearest hospital?
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16. Who is the Health Care Authority in the institution?
17. Is there an inventory of medical equipment available? Are you familiar with its contents?
18. How often are physicals conducted?
19. What is the procedure for transferring inmates with special needs?
20. Do you have a mental health referral procedure?
21. How is suicide watch conducted? Where is it conducted? Do you use inmate
companions?
22. When can restraints be used for medical and/or psychiatric purposes? Who can authorize
the use of restraints?
23. Explain the procedure for clearances for Food Service workers.
24. Female institutions - What type of pre-natal care is provided? What type of counseling is
provided to pregnant inmates?
25. Are all health care providers trained and certified in CPR and AED? Other staff trained?
26. Explain the procedures for detoxification.
27. What are the procedures for first aid kits? AED? Where are they located?
28. What procedures are in place for providing patient education?
29. What is the procedure for the examination and treatment for victims of sexual assault?
30. Are prostheses and orthodontic devices authorized?
31. What types of internal reviews are conducted and how often?
32. What types of external reviews are conducted and how often? Peer Reviews?
33. Are over the counter medications available ? Do inmates pay for these?
34. Check bulk supply rooms for proper storage and inventory of alcohol. Check exam
rooms to determine if alcohol pads are available in limited quantities and secured.
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Mail Room
1. How are packages received/checked?
2. What happens to items not permitted in the institution?
3. What are the legal/special mail procedures?
4. After a package is received, what is the time interval before the inmate recieves the
package?
5. How many packages can an inmate receive per month?
6. What is the procedure for logging packages?
7. What is the procedure if an inmate has been transferred or released and a package arrives
for that inmate?
8. Check to see if directives pertaining to packages are posted and followed.
9. Discuss procedures for receiving inmate funds in the mail.
10. Discuss fire/safety issues.
11. What are the procedures for accepting cash in the mail?
12. What are the procedures for accepting and distributing legal mail?
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Religious Services
1. How often do inmates have access to chaplains?
2. What services are conducted for the population? How often are they conducted? How
many faiths are represented in the inmate population?
3. What type of volunteer programs are used in Religious Services.
4. What types of counseling are available to inmates?
5. Arc other related departments involved in counseling programs?
6. Discuss the notification of death of a family member or death of an inmate procedures.
7. Are visits made to inmates in outside hospitals? How frequently?
8. How frequently do you visit segregation?
9. Discuss fire/safety and control of caustics, toxics and flammables.
10. Is wine used? How is it stored and inventoried? If refrigerated, is there a temperature log
maintained?
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Education
1. What types of programs do you offer? What are the operating hours for education?
2. Do you have formal recognition for inmates' educational accomplishments?
3. How often are the academic programs assessed against State objectives?
4. Do you have access to audio visual materials and equipment?
5. Do you coordinate with other institutional services in instruction in functional social
skills, such as, life skills, family life, or religious programs?
6. Do inmates pay for GED or ABE education?
7. Can an inmate enter an academic program and proceed at his own pace?
8. What college courses are available? Who pays for these courses?
9. Discuss fire/safety and control of caustics, toxics, and flammables.
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Recreation
I. What types of recreation programs arc offered?
2. Is there a weekly schedule of programs posted?
3. Do you have community groups that participate in events with the inmates?
4. What type of hobby craft programs arc offered?
5. Discuss tool control.
6. Discuss how recreation equipment is issued and controlled.
7. Discuss fire/safety issues. When was your last fire drill?
8. Verify procedures are in place for controlling caustics, toxics, and flammables.
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Library
I. What are the hours of operation?
2. How do inmates access the library?
3. Is there an interlibrary loan system in place?
4. How often is the library updated? What is the procedure?
5. Do you have access to a person with a master of library science degree to assist in
coordinating and supervising the library?
6. Do you use inmates as library assistants? How are they trained?
7. Is the library equipped with audio/visual materials? How are they checked out?
8. Discuss fire/safety issues.
9. How do inmates in SHU access the library?
Law Library
1. What are the hours of operation?
2. What are the procedures for inmates to access the law library?
3. How do inmates in SHU gain access?
4. Do you have trained law library inmate clerks? What is their function? How are they
trained?
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VisitinE Room
I. Discuss fire/safety issues - identify exits. Have you participated in a fire drill? What are
the evacuation procedures for the visiting room?
2. Explain visiting procedures (hours of visiting). Regarding visitors: How many can visit?
How often can they visit? How long can they visit?
3. How is an inmate processed in and out of the visiting room?
4. What are the procedures for legal visits?
5. Explain non-contact visiting procedures?
6. How is money from visitors received and logged?
7. Under what conditions can a visit be terminated?
8. What is occupancy capacity in the visiting room?
9. Discuss control of chemicals.
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Food Service Administrator
Your area of responsibility is one of particular interest to ACA auditors and as such, you must be
thoroughly prepared for their visit. In preparation for the type of audit ACA will be doing in
your area, outlined below are items you and your staff should be prepared to discuss/explain in
order to demonstrate compliance with ACA standards.
1. Maintain the highest level of sanitation possible throughout Food Service.
2. If you use foods grown at the institution, be prepared to demonstrate that the items are
inspected and approved by the appropriate agency.
3. How are you notified of "special" diets required by Health Services? How are you
addressing these requirements?
4. Explain the alternate religious fare diet. Who is it for? How do you prepare?
5. Ensure that temperature logs are maintained for ALL freezers and coolers daily, and that
the temperatures recorded fall within the range of the standard. Explain procedures if
temperatures are not within range. Verify stored foods are labeled and covered
completely. (Recommendation: install large thermometers in the back of
coolers/freezers).
6. Explain weekly inspections and how identified deficiencies are corrected.
7. Maintain correct temperatures on dish washing equipment. Explain procedures if the
final rinse temperatures are not maintained? How often is the machine cleaned?
8. Explain how you maintain records of meals served.
9. Explain tool control, including knives and saw blades.
10. Explain procedures for dispensing and controlling "hot" spices, i.e., yeast, nutmeg, etc.
II. Explain budgeting procedures.
17. Ensure staff have pocket thermometers and know how to take the temperatures and what
the correct temperature should be.
13. Ensure signs exist stating "Employees must wash hands, before returning to work".
14. Ensure soap and towels are available at ALL sinks throughout food service.
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15. How long do inmates have to eat meals?
16. Ensure that temperature logs are maintained on coolers/freezers in the Food Service
warehouse.
17. Explain the cycle menu and how it is reviewed by a licensed dietician.
18. Ensure staff and inmates are using gloves, beard covers, hats, and appropriate utensils
when serving.
19. Explain the "clean as you go" policy. Are cleaning procedures posted?
20. Ensure that dishes stacked in the "clean" racks are clean. No greasy pans.
21. Verify pans are placed on racks properly to drain.
22. Verify chemicals arc stored and inventoried properly. Check bin cards.
23. Check vents, overhead grills, and equipment for grease and dirt.
24. Inspect floors for missing tiles, drain covers, excessive water, grease.
25. How often is food rotated? What temperature is dry goods stored at?
26. Explain procedures for inmate physicals.
27. Sanitation! Sanitation! Sanitation! Check for missing or discolored ceiling tiles; make
sure there is no leakage or contamination.
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Armory/Control Center/ Front Lobby
1. How are visitors processed through the main entrance?
2. Are lockers available for visitors to use?
3. What arc the procedures for processing law enforcement officers carrying weapons?
4. Explain key control.
5. Explain emergency procedures. What are they? Why would you use them?
6. In the event of an emergency, how are weapons issued? Who authorizes? Who can be
issued a weapon? How often are weapons inspected? Inventoried?
7. How do you identify weapons which should not be used?
8. Who can authorize the use of chemical agents? What staff are trained in the use of
chemical agents? How are chemical agents issued? How often are they inventoried?
Inspected? How are they controlled? How are expired canisters disposed of?
9. Explain the types of logs you maintain.
10. Explain tool control. How are broken tools disposed of?
11. Have contingency plans been reviewed and signed by all staff?
12. Do you have post orders? Are they signed?
13. Are chemical agents kept in the control room? Verify inventory and check expiration
dates?
14. Verify hand stamp ink (flammable) is controlled and inventoried.
15. Explain procedures for monitoring cameras, issuing keys, tools, and equipment.
16. Explain emergency procedures - 222, no dial, fire.
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UNICOFt/Facilities/Vocational Training/Tool Rooms
I. Explain tool control. How are tools issued to inmates and staff?
2. Explain shadow boards. What do the different colors mean?
3. Verify chemicals are controlled in locked cabinets. Ensure bin cards are accurate.
Explain chemical control policy.
4. Explain daily checklist.
5. Are all exit doors, eyewash stations, and emergency showers free from obstruction?
Ensure eyewash stations are in working order and clean.
6. Be familiar with fire drill procedures. How often are fire drills conducted? Where do
you evacuate to?
7. Explain safety talks. What is included? How often are they conducted?
8. Verify safety protection and procedures are being followed by inmates.
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Power Plant
1. Explain procedures for testing of emergency back up equipment and generators.
2. How much time does it take for power to be restored?
3. What logs are maintained?
4. Is water testing conducted?
5. What are the procedures for chemical and tool control? Verify storage and inventory of
chemicals.
6. Is PPE available, if needed?
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General Items to Look For
1. Sanitation levels throughout the institution. Pay attention to detail cleaning, i.e., grime in
the corners, dust in the window sills, mold in the showers, janitor closets, etc.
2. Open all locked doors to ensure there are no surprises when the auditors conduct their
tour. Mechanical rooms cannot be used for storage.
3. Check to ensure evacuation signs are posted and that they are accurate.
4. Check inventories in all flammable and/or corrosive cabinets. Ensure these cabinets are
secured when staff are not present.
5. Check to ensure that secondary use bottles are labeled correctly and controlled if
necessary.
6. When walking through food service, run your finger over the pans, to ensure they are not
greasy. Check to make sure food particles are not sticking to "clean" dishes and utensils.
7. Make sure MSDS books are legible and accessible.
8. Interview staff as you conduct your walk-throughs. This is your chance to educate them
on the accreditation process and ACA.
9. Check eyewash stations to ensure they are operational and clean.
10. Check all fire extinguishers to ensure they are receiving monthly inspections. Open the
SCBA cabinets to ensure they are being inspected.
11. Check the bather shop to ensure the Barbicide is being controlled. This chemical should
be inventoried in the concentrated form and stored in a corrosive cabinet. Personal
protective clothing should be used when mixing and an eyewash station should be in the
same area where the mixing is occurring. Ensure instruments are properly sanitized.
12. Verify regulations are displayed. Inspect cabinets, drawers, for hair and dirt; ensure there
are towels, neck strips etc. How often is the floor swept?
13. Check the water temperatures in inmate rooms and in the barber shop to verify there is
hot and cold water available throughout.
14. Look for missing or discolored ceiling tiles, peeling paint.
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15. Look for missing drain covers, exposed wiring, unsafe conditions. Check fans and vents
for dirt.
16. Check smoke detectors in housing units and TV rooms to ensure they are operable and
not obstructed.
17. When walking outside, inspect sidewalks, areas outside warehouses, and all areas from
the parking lot to the front entrance for debris and unsafe conditions.
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