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Get CA HHSA DSS LIC 610E 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 610E 10/03 PUBLIC DATE. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES EMERGENCY DISASTER PLAN FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY INSTRUCTIONS Post a copy in a prominent location in facility near telephone. Licensee is responsible for updating information annually. 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 I. 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 NOTIFY FAMILY MEMBERS NOTIFY CCL AND OTHER AGENCIES 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 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. AED IF AVAILABLE - LOCATION VIII. EQUIPMENT SMOKE DETECTOR LOCATION FIRE EXTINGUISHER LOCATION TYPE OF FIRE ALARM SOUNDING DEVICE IF REQUIRED LOCATION OF DEVICE IX. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES EMERGENCY DISASTER PLAN FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY INSTRUCTIONS Post a copy in a prominent location in facility near telephone. Licensee is responsible for updating information annually. 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 I. Licensee is responsible for updating information annually. 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 I. 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 NOTIFY FAMILY MEMBERS NOTIFY CCL AND OTHER AGENCIES II. 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 NOTIFY FAMILY MEMBERS NOTIFY CCL AND OTHER AGENCIES 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. .

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