Form LIC610A "Emergency Disaster Plan for Family Child Care Homes" - California

What Is Form LIC610A?

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 June 1, 2005;
  • 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;

Download a fillable version of Form LIC610A 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 LIC610A "Emergency Disaster Plan for Family Child Care Homes" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES
Type or print clearly. Post next to phone. Keep current - Return a copy to the licensing office.
LICENSEE NAME:
DATE:
1.
EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from:
HOME ADDRESS:
MAJOR CROSSROAD:
HOME DIRECTION FROM CROSSROAD:
2.
EMERGENCY NAMES AND TELEPHONE NUMBERS (In addition to 9-1-1)
Office of Emergency Services:
Fire/Paramedics:
Licensing:
Ambulance:
Other:
Red Cross:
Police/Sheriff:
Child Protective Services:
Hospital:
Poison Control:
3.
FACILITY EVACUATION - Some disasters require evacuation of the building. Using a copy of the Facility Sketch (LIC 999A), show
arrows for the safest way to exit rooms. Be sure that exit doors are not locked from the inside. In the event of a fire, get everyone out,
follow the escape routes, meet at a prearranged location, account for everyone, do not let anyone return to the building and call the fire
department.
4.
TEMPORARY RELOCATION SITE(S) - Some disasters require moving to a safe location. When relocating, determine whether you
need food, water, blankets and flashlight and meet at a prearranged easily accessible location. Be sure to obtain permission from the
property owner.
NAME:
PHONE:
ADDRESS:
NAME:
PHONE:
ADDRESS:
5.
UTILITY SHUT OFF -Indicate locations on the Facility Sketch (LIC 999A) with the exit routes.
GAS:
GAS CO. PHONE:
ELECTRIC:
ELECTRIC CO. PHONE:
WATER:
WATER CO. PHONE:
6.
EQUIPMENT LOCATION - The fire department may help you with installation information.
FIRE EXTINGUISHER LOCATION:
SMOKE DETECTOR LOCATION:
FIRE ALARM LOCATION ( IF YOU HAVE ONE):
TYPE
7.
OTHER EMERGENCY EQUIPMENT - Where appropriate identify location of first aid kit, blankets, food and water, flashlight, radio
and other emergency equipment.
LOCATION:
LIC 610A (6/05) PUBLIC
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES
Type or print clearly. Post next to phone. Keep current - Return a copy to the licensing office.
LICENSEE NAME:
DATE:
1.
EMERGENCIES - LIFE THREATENING - Call 9-1-1 - Tell them: Number Calling from:
HOME ADDRESS:
MAJOR CROSSROAD:
HOME DIRECTION FROM CROSSROAD:
2.
EMERGENCY NAMES AND TELEPHONE NUMBERS (In addition to 9-1-1)
Office of Emergency Services:
Fire/Paramedics:
Licensing:
Ambulance:
Other:
Red Cross:
Police/Sheriff:
Child Protective Services:
Hospital:
Poison Control:
3.
FACILITY EVACUATION - Some disasters require evacuation of the building. Using a copy of the Facility Sketch (LIC 999A), show
arrows for the safest way to exit rooms. Be sure that exit doors are not locked from the inside. In the event of a fire, get everyone out,
follow the escape routes, meet at a prearranged location, account for everyone, do not let anyone return to the building and call the fire
department.
4.
TEMPORARY RELOCATION SITE(S) - Some disasters require moving to a safe location. When relocating, determine whether you
need food, water, blankets and flashlight and meet at a prearranged easily accessible location. Be sure to obtain permission from the
property owner.
NAME:
PHONE:
ADDRESS:
NAME:
PHONE:
ADDRESS:
5.
UTILITY SHUT OFF -Indicate locations on the Facility Sketch (LIC 999A) with the exit routes.
GAS:
GAS CO. PHONE:
ELECTRIC:
ELECTRIC CO. PHONE:
WATER:
WATER CO. PHONE:
6.
EQUIPMENT LOCATION - The fire department may help you with installation information.
FIRE EXTINGUISHER LOCATION:
SMOKE DETECTOR LOCATION:
FIRE ALARM LOCATION ( IF YOU HAVE ONE):
TYPE
7.
OTHER EMERGENCY EQUIPMENT - Where appropriate identify location of first aid kit, blankets, food and water, flashlight, radio
and other emergency equipment.
LOCATION:
LIC 610A (6/05) PUBLIC
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES
Need help filling out the Emergency Disaster Plan Form?
Applicants need to submit a plan to handle possible emergencies. The Emergency Disaster Plan is a plan that
identifies resources when an emergency occurs. A copy of the form must be posted in a conspicuous place near a
telephone and a copy given to the licensing agency with the application packet. Licensee is responsible for updating
information as required and all information should be typed or clearly handwritten.
1. EMERGENCIES - LIFE THREATENING - Whenever a life threatening emergency occurs, use the 9-1-1
telephone number. Operators are able to speed dial help for any life threatening emergency. If the call is
interrupted, they are usually able to identify the home address from the open line. It is important to write out
exactly what needs to be said to direct help to the home. This means that you need to write out the home
phone, the address of the home, the nearest major cross street and directions to the home from the cross
street.
2. EMERGENCY NAMES AND TELEPHONE NUMBERS (In addition to 9-1-1) - This is a list of additional
emergency resources that you may need. Most of the numbers are listed on the form. The Office of
Emergency Services (OES) assists local government and the public with emergencies that threaten lives,
property and the environment. The telephone number for your local OES can be found in the white pages of the
telephone book under Government Listings, County Government Offices, “Emergency Operations”. It may also
be found under County Sheriff’s Department. The “Other” is extra space for other numbers that you think may
be needed in an emergency.
3. FACILITY EVACUATION - The most important action in a fire emergency is getting the children safely out and
grouped together in a safe location. As part of your application packet, you need to complete a facility sketch.
Take a copy of the sketch and identify the quickest exiting routes from each room. Copies of the exiting routes
should be posted in conspicuous locations. You also need to identify a safe location where everyone should
gather to be sure everyone is counted and no one remains in the building. You need to have regular fire
drills with the children. Your fire department is an excellent resource for fire and evacuation instructions.
4. TEMPORARY RELOCATION SITES - In the event of an emergency or disaster, you need to make
arrangements to move to a temporary site, such as at the home of a friend or a local church. You need to
identify a second site in the event the first site is not immediately available in the emergency. Be sure to get
permission from the property owner of the relocation site.
5. UTILITY SHUT OFF - In emergencies such as floods and earthquakes, it may be necessary to shut the utilities
off. It is important to identify the locations of the utility shut off for such emergencies. You should also have a
wrench on hand for the gas line. It also may be helpful to put the utility shut off locations on the Facility Sketch.
6. EQUIPMENT LOCATION - Your home must contain a fire extinguisher and smoke detector device which meet
the standards established by the State Fire Marshal. The fire extinguisher must be in a location that is easily
accessible and identified in this plan. The local fire department may help you with the location of fire equipment.
In addition to smoke alarms, you need to identify and locate any other emergency alarms that are on the
premises. If a fire is just beginning, it may be possible to extinguish the fire with a fire extinguisher. However,
the children should be safely relocated before attempting to extinguish any fire.
7. OTHER EMERGENCY EQUIPMENT - In the event of a flood or earthquake, it may be necessary to have a
first aid kit, blankets, food and water, radio, flashlight and other provisions. The plan needs to identify where
this other emergency equipment is kept.
LIC 610A (6/05)
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