S FOR THE CHRONICALLY ILL (PUBLIC) EXPLANATION: This form is provided as a courtesy to all adult facility applicants and licensees. An applicant seeking a license for a new Adult Day Program (ADP), Adult Residential Facility (ARF), Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN), Community Crisis Home (CCH), Enhanced Behavioral Supports Home (EBSH), Residential Care Facility for the Chronically Ill (RCFCI), and Social Rehabilitation Facility (SRF) must submit an e.

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How to fill out the CA LIC 610D online

The CA LIC 610D is an essential document for adult community care facilities and residential care facilities for the chronically ill. This guide provides a step-by-step approach to completing the form online, ensuring that you meet all necessary requirements.

Follow the steps to successfully complete the CA LIC 610D form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Enter the name of the facility and license number in the designated fields.
  3. Provide the street address, city, state, zip code, and contact details including alternate telephone number and cell phone number.
  4. Proceed to section A, where you will list emergency names and telephone numbers, including contact for ambulance, fire department, police, and local emergency services.
  5. In section B, assign responsibilities during an emergency or disaster, indicating the name and title of the facility staff responsible for each task.
  6. Complete section C by providing resident/client information, ensuring that all details are readily available during an emergency.
  7. Fill in section D regarding utility shut-off locations and instructions for each utility (electricity, gas, sewer, water).
  8. In section E, specify the locations of all exit doors within the facility.
  9. Detail temporary shelter locations in section G and ensure at least two options are provided.
  10. Outline sheltering in place procedures in section H, specifying plans and supplies for utility outages.
  11. In section I, outline planned evacuation procedures and ensure transportation needs are addressed.
  12. Articulate emergency and disaster procedures in section J that address key operational needs during emergencies.
  13. Ensure to include the administrator statement in section K, affirming responsibility for the plan's accuracy.
  14. Finally, complete the review history section L, marking review and update dates with corresponding signatures.
  15. Once all sections have been completed, save changes, download, print, or share the form as needed.

Complete your CA LIC 610D form online today to ensure compliance with safety regulations.

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