Form LIC 610C at a glance
What it is: California Department of Social Services Emergency Disaster Plan for Children's Residential Facilities (except foster family homes).
Where and when to file: Return a copy to the licensing office.
Licensee is responsible for updating information as required.
A filled-in Form LIC 610C example: an administrator completes the plan
How to fill out Form LIC 610C, box by box
Facility, administrator and address
Enter the Name of Facility and the Administrator of Facility.
Enter the Facility Address (Number, Street, City, State, Zip Code) and the Telephone number.
I. Assignments during an emergency
Use the reverse side if additional space is required for I. Assignments During an Emergency.
Enter the Name(s) of Staff and Title for each assignment: Direct Evacuation and Person Count, Handle First Aid, Telephone Emergency Numbers, Transportation, and Other (Describe).
II. Emergency names and telephone numbers
In addition to 9-1-1, enter the name and telephone number for Fire/Paramedics, Police or Sheriff, Red Cross, Office of Emergency Services, Hospital(s), Poison Control, Dentist(s), Ambulance, Child Protective Services, Crisis Center and Other Agency/Person.
III. Facility exit locations
Using a copy of the Facility Sketch [LIC 999], indicate exits by number.
IV. Temporary relocation sites
If available, submit a letter of permission from the renter/lessee/manager/property owner, and enter the Name, Address and Telephone Number for each Temporary Relocation Site.
V. Utility shut-off locations
Indicate the location(s) of the Electricity, Water and Gas shut-off on the Facility Sketch [LIC 999].
VII. Equipment
Under VII. Equipment, enter the Smoke Detector Location (if required), the Fire Extinguisher Location (if required) and the Type of Fire Alarm Sounding Device (if required), with the Location of Device.
VIII. Affirmation statement
As administrator of this facility, the administrator assumes responsibility for this plan for providing emergency services as indicated.
The administrator 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.
Under VIII. Affirmation Statement, sign under Signature and enter the Date.
More rules for Form LIC 610C
Post a copy in a prominent location in facility, near telephone.
Common questions about Form LIC 610C
Where do I file it?
Return a copy to the licensing office.
When is this form not the right one?
California Department of Social Services Emergency Disaster Plan for Children's Residential Facilities (except foster family homes).
Sources
[1] Form LIC 610C (10/03), Emergency Disaster Plan for Children's Residential Facilities, California Department of Social Services (the Official source link on this page).