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Get CA LIC 610C 2003

Minent location in facility, near telephone. Licensee is responsible for updating information as required. Return a copy to the licensing office. (EXCEPT FOSTER FAMILY HOMES) NAME OF FACILITY FACILITY ADDRESS I. ADMINISTRATOR OF FACILITY (NUMBER, STREET, CITY, STATE, ZIP CODE) TELEPHONE ( ) ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED) TITLE ASSIGNMENT NAME(S) OF STAFF 1. DIRECT EVACUATION AND PERSON COUNT 2. HANDLE FIRST AID 3. TELEPHONE E.

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