Form Lic 610C PDF Details

In the face of emergencies, preparedness becomes the spine of safety, especially for children’s residential facilities which require a meticulous plan to ensure the wellbeing of their occupants. The State of California, through the Health and Human Services Agency and California Department of Social Services, mandates the creation of an Emergency Disaster Plan, outlined in the LIC 610C form, for such facilities with the exception of foster family homes. This comprehensive form serves as a crucial tool in orchestrating a structured response to unforeseen emergencies by detailing specific assignments for staff members that include direct evacuation, first aid, and communication with emergency services among others. Facilities are required to prominently display a copy of this plan and keep it up to date, further submitting a copy to the licensing office. The document also demands the recording of essential emergency contacts beyond 9-1-1, such as fire/paramedics, police or sheriff, and hospital information. It emphasizes the importance of clearly mapping facility exit locations, temporary relocation sites, utility shut-off locations, and the positioning of vital emergency equipment such as smoke detectors and fire extinguishers. By signing an affirmation statement, administrators declare their commitment to implementing and maintaining this emergency disaster plan, underscoring the collective responsibility to protect and instruct all residents and staff in their roles during a crisis. Thus, the LIC 610C form embodies a critical framework designed to enhance safety protocols and ensure a coordinated response to emergencies within children’s residential facilities.

QuestionAnswer
Form NameForm Lic 610C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslic 610c form fillable, form lic610c, lic 610c form california, lic610c emergency disaster plan

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

EMERGENCY DISASTER PLAN FOR CHILDREN’S RESIDENTIAL FACILITIES

(EXCEPT FOSTER FAMILY HOMES)

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.

NAME OF FACILITY

 

 

ADMINISTRATOR OF FACILITY

 

 

 

 

 

 

 

 

 

 

 

FACILITY ADDRESS

(NUMBER, STREET,

CITY,

STATE,

ZIP CODE)

TELEPHONE

 

(

)

 

 

 

 

 

 

 

I.ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)

 

NAME(S) OF STAFF

TITLE

ASSIGNMENT

 

1.

 

DIRECT EVACUATION AND PERSON COUNT

 

 

 

 

 

 

2.

 

HANDLE FIRST AID

 

 

 

 

 

 

3.

 

TELEPHONE EMERGENCY NUMBERS

 

 

 

 

 

4.

 

TRANSPORTATION

 

 

 

 

 

5.

 

OTHER (DESCRIBE)

 

6.

II.EMERGENCY NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)

FIRE/PARAMEDICS

POLICE OR SHERIFF

RED CROSS

OFFICE OF EMERGENCY SERVICES

HOSPITAL(S)

POISON CONTROL

DENTIST(S)

AMBULANCE

CHILD PROTECTIVE SERVICES

CRISIS CENTER

OTHER AGENCY/PERSON

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/LESSEE/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. EQUIPMENT

SMOKE DETECTOR LOCATION (IF REQUIRED)

FIRE EXTINGUISHER LOCATION (IF REQUIRED)

TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)

LOCATION OF DEVICE

VIII. 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 610C (10/03) (PUBLIC)

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How to complete lic610c emergency disaster plan stage 1

2. Now that the last array of fields is completed, it is time to put in the essential particulars in DENTISTS, CHILD PROTECTIVE SERVICES, AMBULANCE, CRISIS CENTER, OTHER AGENCYPERSON, III FACILITY EXIT LOCATIONS USING, IV TEMPORARY RELOCATION SITES IF, ADDRESS, TELEPHONE NUMBER TELEPHONE, NAME, ADDRESS, V UTILITY SHUTOFF LOCATIONS, WATER, GAS, and VI FIRST AID KIT LOCATION so that you can go further.

lic610c emergency disaster plan writing process detailed (part 2)

3. This part is going to be simple - fill in all the form fields in AS ADMINISTRATOR OF THIS FACILITY, SIGNATURE, LIC C PUBLIC, and DATE in order to finish this segment.

lic610c emergency disaster plan conclusion process explained (part 3)

Be extremely careful while filling out LIC C PUBLIC and SIGNATURE, since this is where most users make errors.

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