Form LIC610E "Emergency Disaster Plan for Residential Care Facilities for the Elderly" - California

What Is Form LIC610E?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC610E by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC610E "Emergency Disaster Plan for Residential Care Facilities for the Elderly" - California

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State of California – Health and Human Services Agency
California Department of Social Services
EMERGENCY AND DISASTER PLAN
FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: A licensee is required to have an emergency and disaster plan that includes all of
the elements on this form pursuant to Health and Safety Code
section 1569.695
and California Code
of Regulations, Title 22,
Section
87212, Emergency Disaster Plan. The plan must be in writing and
made available upon request to residents onsite, any responsible party for a resident, local long-term
care ombudsman, and local emergency responders. All resident and employee information on
this form must be kept confidential.
A licensee must provide training on the plan to all staff upon hire and annually thereafter. The training
must include staff responsibilities during an emergency or disaster. Drills must be conducted by a
licensee at least quarterly for each shift. The type of emergency covered in the drills must vary from
quarter to quarter as specified in Health and Safety Code
section
1569.695(c). An actual evacuation
of residents is not required during a drill. While a licensee may provide an opportunity for
residents to participate in a drill, they may not require resident participation. Documentation of drills
must include the date, the type of emergency covered by the drill, and the names of facility staff
participating in the drill.
The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. A
licensee or administrator shall sign and date the plan to show that it has been reviewed and updated
as necessary. A licensee is encouraged, but not required, to have the plan reviewed by local
emergency authorities.
Note: An applicant seeking a license for a new facility must submit an emergency and disaster plan
with their initial license application.
This form is provided as a courtesy to applicants and licensees.
Table of Contents
Section
Page
2
Assignments During an Emergency or Disaster
3
Resident Information
3
Utility Shut-Off
3
Facility Exit Doors
3
Resident Assembly Points
4
Temporary Shelter Locations
4
Sheltering in Place Procedures
5
Evacuation Procedures
6
Emergency and Disaster Procedures
9
Administrator Statement
9
Review History
LIC 610E (3/19)
Page 1 of 9
State of California – Health and Human Services Agency
California Department of Social Services
EMERGENCY AND DISASTER PLAN
FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: A licensee is required to have an emergency and disaster plan that includes all of
the elements on this form pursuant to Health and Safety Code
section 1569.695
and California Code
of Regulations, Title 22,
Section
87212, Emergency Disaster Plan. The plan must be in writing and
made available upon request to residents onsite, any responsible party for a resident, local long-term
care ombudsman, and local emergency responders. All resident and employee information on
this form must be kept confidential.
A licensee must provide training on the plan to all staff upon hire and annually thereafter. The training
must include staff responsibilities during an emergency or disaster. Drills must be conducted by a
licensee at least quarterly for each shift. The type of emergency covered in the drills must vary from
quarter to quarter as specified in Health and Safety Code
section
1569.695(c). An actual evacuation
of residents is not required during a drill. While a licensee may provide an opportunity for
residents to participate in a drill, they may not require resident participation. Documentation of drills
must include the date, the type of emergency covered by the drill, and the names of facility staff
participating in the drill.
The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. A
licensee or administrator shall sign and date the plan to show that it has been reviewed and updated
as necessary. A licensee is encouraged, but not required, to have the plan reviewed by local
emergency authorities.
Note: An applicant seeking a license for a new facility must submit an emergency and disaster plan
with their initial license application.
This form is provided as a courtesy to applicants and licensees.
Table of Contents
Section
Page
2
Assignments During an Emergency or Disaster
3
Resident Information
3
Utility Shut-Off
3
Facility Exit Doors
3
Resident Assembly Points
4
Temporary Shelter Locations
4
Sheltering in Place Procedures
5
Evacuation Procedures
6
Emergency and Disaster Procedures
9
Administrator Statement
9
Review History
LIC 610E (3/19)
Page 1 of 9
State of California – Health and Human Services Agency
California Department of Social Services
Name of Facility and License Number
Administrator of Facility
Street Address
City
State
Zip Code
Telephone Number
Alternate Telephone Number Cell Phone Number
EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)
Emergency Contact Name
Telephone Number
Ambulance/Paramedics
Fire Department
Poison Control
Police/Sheriff
Office of Emergency Services
Red Cross
Transportation Provider(s)
Community Care Licensing (CCL) Adult and Senior Care Regional Office
Local Long-Term Care Ombudsman
Adult Protective Services
County Mental Health
Note: Emergency numbers must be posted at the facility.
ASSIGNMENTS DURING AN EMERGENCY OR DISASTER
Facility Staff Member(s) Responsible
Assignment
Name
Title
Accessing emergency supplies
Utility shut-off and if applicable, operation of backup
generator
Provide transportation
Direct evacuation, assembly of residents to
predetermined evacuation site, and person count
Supervision of residents during evacuation and/or
relocation
Contact local emergency response agencies, CCL,
residents’ representatives, hospice providers,
local Long-Term Care Ombudsman, transportation
providers, and others as necessary
LIC 610E (3/19)
Page 2 of 9
State of California – Health and Human Services Agency
California Department of Social Services
RESIDENT INFORMATION
(TO BE READILY AVAILABLE TO FACILITY STAFF DURING AN EMERGENCY)
Information
Location
Roster of residents with date of birth for each resident
Appraisal of resident needs and services for each resident
Medication list for residents with centrally stored medications
Contact information for the responsible party and physician for each resident
Note: This information must be located in the facility to ensure all information and records obtained from or
regarding residents is kept confidential as required by California Code of Regulations, Title 22,
Section
87506,
Resident Records.
UTILITY SHUT-OFF
Utility
Shut-Off Location
Instructions for Shut-Off
Electricity
Gas
Sewer
Water
Other
FACILITY EXIT DOORS
Exit Door
Location
RESIDENT ASSEMBLY POINTS
Assembly Point
Location
Note: A licensee must show the location of all resident assembly points on the facility sketch.
LIC 610E (3/19)
Page 3 of 9
State of California – Health and Human Services Agency
California Department of Social Services
TEMPORARY SHELTER LOCATIONS
Name
Address
Telephone Number
Note: A licensee must list at least two appropriate shelter locations that can house facility residents during
an evacuation and are equipped to provide safe temporary accommodations. One of the locations must be
outside the immediate area where the facility is located.
SHELTERING IN PLACE PROCEDURES
If the facility plans to shelter-in-place, indicate the planned sheltering-in-place procedures. In
case one or more utilities, including water, sewer, gas, or electricity, is not available, specify
the plan and supplies available to provide alternative resources during an outage.
Specify plan for the facility to be self-reliant for a period of not less than 72 hours immediately
following any emergency or disaster, including, but not limited to, a short-term or long-term
power failure.
LIC 610E (3/19)
Page 4 of 9
State of California – Health and Human Services Agency
California Department of Social Services
EVACUATION PROCEDURES
Indicate the planned evacuation procedures.
Identify transportation needs.
Note: If transportation plan includes use of vehicle owned or operated by the facility, the keys to the vehicle
shall be available to staff on all shifts.
Procedures to ensure communication with emergency response personnel and access to
information needed to check emergency routes to be used for evacuation and relocation
during an emergency or disaster.
LIC 610E (3/19)
Page 5 of 9