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Get CA LIC 610D 2003

AFFIRMATION STATEMENT 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 LIC 610D 10/03 PUBLIC DATE. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES EMERGENCY DISASTER PLAN FOR ADULT DAY PROGRAMS ADULT RESIDENTIAL FACILITIES RESIDENTIAL CARE FACILITIES FOR THE CHRONICALLY ILL AND SOCIAL REHABILITATION FACILITIES NAME OF FACILITY FACILITY ADDRESS I. INSTRUCTIONS Post a copy in a prominent location in facility near telephone. Licensee is responsible for updating information as required* Return a copy to the licensing office. ADMINISTRATOR OF FACILITY NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER ASSIGNMENTS DURING AN EMERGENCY USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED TITLE ASSIGNMENT NAME S OF STAFF DIRECT EVACUATION AND PERSON COUNT HANDLE FIRST AID TELEPHONE EMERGENCY NUMBERS TRANSPORTATION OTHER DESCRIBE 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 CRISIS CENTER LONG TERM OMBUDSMAN OTHER AGENCY/PERSON III. FACILITY EXIT LOCATIONS USING A COPY OF THE FACILITY SKETCH LIC 999 INDICATE EXITS BY NUMBER IV. TEMPORARY RELOCATION SITE S IF AVAILABLE SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER NAME ADDRESS V. UTILITY SHUT OFF LOCATIONS INDICATE LOCATION S ON THE FACILITY SKETCH LIC 999 ELECTRICITY WATER GAS VI. FIRST AID KIT LOCATION VII. EQUIPMENT SMOKE DETECTOR LOCATION IF REQUIRED FIRE EXTINGUISHER LOCATION IF REQUIRED TYPE OF FIRE ALARM SOUNDING DEVICE IF REQUIRED LOCATION OF DEVICE VIII. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES EMERGENCY DISASTER PLAN FOR ADULT DAY PROGRAMS ADULT RESIDENTIAL FACILITIES RESIDENTIAL CARE FACILITIES FOR THE CHRONICALLY ILL AND SOCIAL REHABILITATION FACILITIES NAME OF FACILITY FACILITY ADDRESS I. INSTRUCTIONS Post a copy in a prominent location in facility near telephone. Licensee is responsible for updating information as required* Return a copy to the licensing office. INSTRUCTIONS Post a copy in a prominent location in facility near telephone. Licensee is responsible for updating information as required* Return a copy to the licensing office. ADMINISTRATOR OF FACILITY NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER ASSIGNMENTS DURING AN EMERGENCY USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED TITLE ASSIGNMENT NAME S OF STAFF DIRECT EVACUATION AND PERSON COUNT HANDLE FIRST AID TELEPHONE EMERGENCY NUMBERS TRANSPORTATION OTHER DESCRIBE II. ADMINISTRATOR OF FACILITY NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER ASSIGNMENTS DURING AN EMERGENCY USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED TITLE ASSIGNMENT NAME S OF STAFF DIRECT EVACUATION AND PERSON COUNT HANDLE FIRST AID TELEPHONE EMERGENCY NUMBERS TRANSPORTATION OTHER DESCRIBE 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 CRISIS CENTER LONG TERM OMBUDSMAN OTHER AGENCY/PERSON III. .

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