Form Lic 610D PDF Details

In the realm of healthcare and social services, ensuring the safety and preparedness of facilities catering to vulnerable populations is paramount. This priority is embodied in the requirement for certain facilities in California to adopt and maintain the LIC 610D form, a comprehensive emergency disaster plan mandated by the California Department of Social Services. The LIC 610D form is specifically designed for adult day programs, adult residential facilities, residential care facilities for the chronically ill, and social rehabilitation facilities. It outlines a framework for disaster readiness, including the designation of staff roles during an emergency, a compilation of essential emergency contact numbers, and plans for evacuation and temporary relocation. Facilities are required to conspicuously post a copy of this plan and ensure it is regularly updated to reflect any changes. The form also mandates documenting utility shut-off locations, the whereabouts of first aid kits, and the positioning of emergency equipment like smoke detectors and fire extinguishers. Beyond the logistical components, the LIC 610D demands an affirmation from the facility's administrator, asserting their commitment to the plan and their role in educating all inhabitants and staff about their responsibilities in the face of a disaster. This comprehensive approach underscores the state's commitment to safeguarding its most vulnerable citizens through meticulous preparation and clear communication channels in the event of an emergency.

QuestionAnswer
Form NameForm Lic 610D
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslic610d, lic 610d form, emergency disaster adult, lic 610d adult programs

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

EMERGENCY DISASTER PLAN FOR ADULT DAY PROGRAMS, ADULT RESIDENTIAL FACILITIES, RESIDENTIAL CARE FACILITIES FOR THE CHRONICALLY ILL AND SOCIAL REHABILITATION FACILITIES

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 NUMBER

( )

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

PHYSICIAN(S)

POISON CONTROL

HOSPITAL(S)

AMBULANCE

DENTIST(S)

CRISIS CENTER

LONG TERM OMBUDSMAN

OTHER AGENCY/PERSON

III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)

1.

3.

2.

4.

IV. TEMPORARY RELOCATION SITE(S) (IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/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 610D (10/03) (PUBLIC)

How to Edit Form Lic 610D Online for Free

Our PDF editor was made to be as clear as it can be. While you keep to the following actions, the process of filling in the lic 610d 10 03 public document will be straightforward.

Step 1: The first step will be to choose the orange "Get Form Now" button.

Step 2: After you've entered the lic 610d 10 03 public editing page you can discover every one of the functions you may conduct relating to your document from the upper menu.

The next parts will compose the PDF document that you will be filling in:

entering details in emergency disaster plan form step 1

The system will expect you to prepare the HOSPITALS, DENTISTS, AMBULANCE, CRISIS CENTER, LONG TERM OMBUDSMAN, OTHER AGENCYPERSON, III FACILITY EXIT LOCATIONS USING, IV TEMPORARY RELOCATION SITES IF, ADDRESS, TELEPHONE NUMBER TELEPHONE, NAME, ADDRESS, V UTILITY SHUTOFF LOCATIONS, WATER, and GAS box.

step 2 to entering details in emergency disaster plan form

Outline the key data in the LOCATION OF DEVICE, VIII AFFIRMATION STATEMENT AS, DATE, and LIC D PUBLIC field.

part 3 to filling out emergency disaster plan form

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Step 4: You could make duplicates of your form toavoid all of the potential future complications. Don't be concerned, we do not disclose or check your data.

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