Lic 610E Form PDF Details

The Lic 610E form is an important document for businesses in New York State. This form is used to apply for a Business Certificate and to register with the Tax Department. The Tax Department uses this information to determine a business's tax liability. Filing this form correctly is critical, so make sure you are familiar with the requirements. For more information, consult the instructions provided by the Tax Department.

Below are some specifics of lic 610e form. You can read it before typing in the gaps.

QuestionAnswer
Form NameLic 610E Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other nameslic 610e, lic 610e form california, lic 610e 3 19, emergency disaster residential facilities

Form Preview Example

State of California ­– Health and Human Services Agency

California Department of Social Services

EMERGENCY AND DISASTER PLAN

FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

EXPLANATION: A licensee is required to have an emergency and disaster plan that includes all of the elements on this form pursuant to Health and Safety Code section 1569.695 and California Code of Regulations, Title 22, Section 87212, Emergency Disaster Plan. The plan must be in writing and made available upon request to residents onsite, any responsible party for a resident, local long-term care ombudsman, and local emergency responders. All resident and employee information on this form must be kept confidential.

A licensee must provide training on the plan to all staff upon hire and annually thereafter. The training must include staff responsibilities during an emergency or disaster. Drills must be conducted by a licensee at least quarterly for each shift. The type of emergency covered in the drills must vary from quarter to quarter as specified in Health and Safety Code section 1569.695(c). An actual evacuation of residents is not required during a drill. While a licensee may provide an opportunity for residents to participate in a drill, they may not require resident participation. Documentation of drills must include the date, the type of emergency covered by the drill, and the names of facility staff participating in the drill.

The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. A licensee or administrator shall sign and date the plan to show that it has been reviewed and updated as necessary. A licensee is encouraged, but not required, to have the plan reviewed by local emergency authorities.

Note: An applicant seeking a license for a new facility must submit an emergency and disaster plan with their initial license application.

This form is provided as a courtesy to applicants and licensees.

Table of Contents

Section

Assignments During an Emergency or Disaster

Resident Information

Utility Shut-Off

Facility Exit Doors

Resident Assembly Points

Temporary Shelter Locations

Sheltering in Place Procedures

Evacuation Procedures

Emergency and Disaster Procedures

Administrator Statement

Review History

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9

9

LIC 610E (3/19)

Page 1 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

Name of Facility and License Number

 

Administrator of Facility

 

 

 

 

Street Address

City

State

Zip Code

 

 

 

 

Telephone Number

Alternate Telephone Number

Cell Phone Number

 

 

 

 

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

Emergency Contact Name

Telephone Number

Ambulance/Paramedics

Fire Department

Poison Control

Police/Sheriff

Office of Emergency Services

Red Cross

Transportation Provider(s)

Community Care Licensing (CCL) Adult and Senior Care Regional Office

Local Long-Term Care Ombudsman

Adult Protective Services

County Mental Health

Note: Emergency numbers must be posted at the facility.

ASSIGNMENTS DURING AN EMERGENCY OR DISASTER

Assignment

Facility Staff Member(s) Responsible

Name

Title

 

Accessing emergency supplies

Utility shut-off and if applicable, operation of backup generator

Provide transportation

Direct evacuation, assembly of residents to predetermined evacuation site, and person count

Supervision of residents during evacuation and/or relocation

Contact local emergency response agencies, CCL, residents’ representatives, hospice providers, local Long-Term Care Ombudsman, transportation providers, and others as necessary

LIC 610E (3/19)

Page 2 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

RESIDENT INFORMATION

(TO BE READILY AVAILABLE TO FACILITY STAFF DURING AN EMERGENCY)

Information

Location

Roster of residents with date of birth for each resident

Appraisal of resident needs and services for each resident

Medication list for residents with centrally stored medications

Contact information for the responsible party and physician for each resident

Note: This information must be located in the facility to ensure all information and records obtained from or regarding residents is kept confidential as required by California Code of Regulations, Title 22, Section 87506, Resident Records.

UTILITY SHUT-OFF

Utility

Shut-Off Location

Instructions for Shut-Off

Electricity

Gas

Sewer

Water

Other

FACILITY EXIT DOORS

Exit Door

Location

RESIDENT ASSEMBLY POINTS

Assembly Point

Location

Note: A licensee must show the location of all resident assembly points on the facility sketch.

LIC 610E (3/19)

Page 3 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

TEMPORARY SHELTER LOCATIONS

Name

Address

Telephone Number

Note: A licensee must list at least two appropriate shelter locations that can house facility residents during an evacuation and are equipped to provide safe temporary accommodations. One of the locations must be outside the immediate area where the facility is located.

SHELTERING IN PLACE PROCEDURES

If the facility plans to shelter-in-place, indicate the planned sheltering-in-place procedures. In case one or more utilities, including water, sewer, gas, or electricity, is not available, specify the plan and supplies available to provide alternative resources during an outage.

Specify plan for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure.

LIC 610E (3/19)

Page 4 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

EVACUATION PROCEDURES

Indicate the planned evacuation procedures.

Identify transportation needs.

Note: If transportation plan includes use of vehicle owned or operated by the facility, the keys to the vehicle shall be available to staff on all shifts.

Procedures to ensure communication with emergency response personnel and access to information needed to check emergency routes to be used for evacuation and relocation during an emergency or disaster.

LIC 610E (3/19)

Page 5 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

EMERGENCY AND DISASTER PROCEDURES

List procedures that address:

A.Provisions for emergency power (could include identifying suppliers of, and obtaining, back-up generators).

B.Responding to individual residents’ needs if emergency call buttons are inoperable.

C.Operating assistive medical devices that need electric power for operation, including, but not limited to, oxygen equipment and wheelchairs.

LIC 610E (3/19)

Page 6 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

D.Communicating with residents, families, hospice providers, and others as appropriate (may include landline telephones, cellular telephones, or walkie-talkies), establish backup communication, and inform residents and their responsible parties of the process for communicating during an emergency or disaster.

E.Assisting residents with self-administration of medication, and administering medication to residents.

F.Storage and preservation of medications, including storing medications that require refrigeration.

LIC 610E (3/19)

Page 7 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

G.Identifying residents with special needs, such as hospice services, and plan for meeting those needs.

H. Confirming the location of each resident during an emergency or disaster.

LIC 610E (3/19)

Page 8 of 9

State of California ­– Health and Human Services Agency

California Department of Social Services

 

 

 

 

ADMINISTRATOR STATEMENT

As licensee or administrator of this facility, I assume responsibility for and have reviewed this plan for providing emergency services, and as necessary, have updated it to reflect any changes in the facility that affect this plan, as indicated below. I shall instruct all residents, age and abilities permitting, any staff and/or household members as needed on their duties and responsibilities under this plan.

 

Reviewed/Updated

Date

Name and Title

Signature

 

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LIC 610E (3/19)

 

 

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filling out lic 610e rcfe step 1

Complete the NameofFacilityandLicenseNumber, AdministratorofFacility, StreetAddress, TelephoneNumber, City, State, and ZipCode fields with any information that are requested by the system.

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The system will ask you for details to conveniently submit the area FacilityStaffMembersResponsible, Name, Title, and Assignment.

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The LICE, and Pageof section could be used to indicate the rights and responsibilities of both parties.

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Check the sections Location, UTILITYSHUTOFF, ShutOffLocation, InstructionsforShutOff, ExitDoor, Location, and FACILITYEXITDOORS and next complete them.

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