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

This version of the form is not currently in use and is provided for reference only.
Download this version of Form LIC610E for the current year.

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 October 1, 2003;
  • 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.

ADVERTISEMENT
ADVERTISEMENT

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

824 times
Rate (4.5 / 5) 52 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS:
EMERGENCY DISASTER PLAN FOR
Post a copy in a prominent location in facility, near telephone.
RESIDENTIAL CARE FACILITIES
Licensee is responsible for updating information annually.
FOR THE ELDERLY
Return a copy to the licensing office.
NAME OF FACILITY
ADMINISTRATOR OF FACILITY
FACILITY ADDRESS
(NUMBER,
STREET,
CITY,
STATE,
ZIP CODE)
TELEPHONE NUMBER
(
)
FAX NUMBER
CELL PHONE NUMBER
(
)
(
)
I.
ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)
NAME(S) OF STAFF
TITLE
ASSIGNMENT
DIRECT EVACUATION AND PERSON COUNT
1.
HANDLE FIRST AID
2.
TELEPHONE EMERGENCY NUMBERS
3.
TRANSPORTATION
4.
NOTIFY FAMILY MEMBERS
5.
NOTIFY CCL AND OTHER AGENCIES
6.
II.
EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)
FIRE/PARAMEDICS
POLICE OR SHERIFF
RED CROSS
OFFICE OF EMERGENCY SERVICES
PHYSICIAN(S)
POISON CONTROL
HOSPITAL(S)
AMBULANCE
DENTIST(S)
ADULT PROTECTIVE SERVICES
LONG TERM OMBUDSMAN
OTHER AGENCY/PERSON
COUNTY MENTAL HEALTH
III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
1.
2.
3.
4.
IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER)
NAME
ADDRESS
TELEPHONE NUMBER
(
)
NAME
ADDRESS
TELEPHONE NUMBER
(
)
V.
UTILITY SHUT—OFF LOCATIONS (INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
ELECTRICITY
WATER
GAS
VI. FIRST AID KIT (LOCATION)
VII. AED (IF AVAILABLE - LOCATION)
VIII. EQUIPMENT
SMOKE DETECTOR LOCATION
FIRE EXTINGUISHER LOCATION
TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
LOCATION OF DEVICE
IX. AFFIRMATION STATEMENT
AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS
INDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR
HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.
SIGNATURE
DATE
LIC 610E (10/03) (PUBLIC)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INSTRUCTIONS:
EMERGENCY DISASTER PLAN FOR
Post a copy in a prominent location in facility, near telephone.
RESIDENTIAL CARE FACILITIES
Licensee is responsible for updating information annually.
FOR THE ELDERLY
Return a copy to the licensing office.
NAME OF FACILITY
ADMINISTRATOR OF FACILITY
FACILITY ADDRESS
(NUMBER,
STREET,
CITY,
STATE,
ZIP CODE)
TELEPHONE NUMBER
(
)
FAX NUMBER
CELL PHONE NUMBER
(
)
(
)
I.
ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)
NAME(S) OF STAFF
TITLE
ASSIGNMENT
DIRECT EVACUATION AND PERSON COUNT
1.
HANDLE FIRST AID
2.
TELEPHONE EMERGENCY NUMBERS
3.
TRANSPORTATION
4.
NOTIFY FAMILY MEMBERS
5.
NOTIFY CCL AND OTHER AGENCIES
6.
II.
EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)
FIRE/PARAMEDICS
POLICE OR SHERIFF
RED CROSS
OFFICE OF EMERGENCY SERVICES
PHYSICIAN(S)
POISON CONTROL
HOSPITAL(S)
AMBULANCE
DENTIST(S)
ADULT PROTECTIVE SERVICES
LONG TERM OMBUDSMAN
OTHER AGENCY/PERSON
COUNTY MENTAL HEALTH
III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
1.
2.
3.
4.
IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER)
NAME
ADDRESS
TELEPHONE NUMBER
(
)
NAME
ADDRESS
TELEPHONE NUMBER
(
)
V.
UTILITY SHUT—OFF LOCATIONS (INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
ELECTRICITY
WATER
GAS
VI. FIRST AID KIT (LOCATION)
VII. AED (IF AVAILABLE - LOCATION)
VIII. EQUIPMENT
SMOKE DETECTOR LOCATION
FIRE EXTINGUISHER LOCATION
TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
LOCATION OF DEVICE
IX. AFFIRMATION STATEMENT
AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES AS
INDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/OR
HOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS PLAN.
SIGNATURE
DATE
LIC 610E (10/03) (PUBLIC)