STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES …

1 DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)INSTRUCTIONS:Post a copy in a prominent location in facility, near is responsible for updating information a copy to the licensing office. III. FACILITY EXIT LOCATIONS (USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)IV. TEMPORARY RELOCATION SITE(S)(IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASEE/MANAGER/PROPERTY OWNER) SHUT OFF LOCATIONS(INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])AS ADMINISTRATOR OF THIS FACILITY, I ASSUME RESPONSIBILITY FOR THIS PLAN FOR PROVIDING EMERGENCY SERVICES ASINDICATED BELOW. I SHALL INSTRUCT ALL CLIENTS/RESIDENTS, AGE AND ABILITIES PERMITTING, ANY STAFF AND/ORHOUSEHOLD MEMBERS AS NEEDED IN THEIR DUTIES AND RESPONSIBILITIES UNDER THIS AFFIRMATION STATEMENTLIC 610E (10/03) (PUBLIC)VI.

2 FIRST AID KIT (LOCATION)VII. AED (IF AVAILABLE - LOCATION) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA department OF social SERVICESEMERGENCY DISASTER PLAN FORRESIDENTIAL CARE FACILITIES FOR THE ELDERLYNAME OF FACILITYFAX NUMBERNAME(S) OF STAFFTITLEASSIGNMENTADMINISTRATOR OF FACILITYTELEPHONE NUMBERFACILITY ADDRESS (NUMBER,STREET,CITY, STATE ,ZIP CODE)( )( )CELL PHONE NUMBER( )( )( ) EVACUATION AND PERSON COUNTHANDLE FIRST AIDTELEPHONE EMERGENCY NUMBERSTRANSPORTATIONNOTIFY FAMILY MEMBERSNOTIFY CCL AND OTHER NAMES AND TELEPHONE NUMBERS (IN ADDITION TO 9-1-1)VIII. EQUIPMENTFIRE/PARAMEDICSRED CROSSPHYSICIAN(S)HOSPITAL(S)DENTIST(S)EL ECTRICITYWATERGASPOLICE OR SHERIFFOFFICE OF EMERGENCY SERVICESPOISON CONTROLAMBULANCEADULT PROTECTIVE SERVICESOTHER AGENCY/PERSONLONG TERM OMBUDSMANCOUNTY MENTAL HEALTHTELEPHONE NUMBERTELEPHONE NUMBERSMOKE DETECTOR LOCATIONFIRE EXTINGUISHER LOCATIONTYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)LOCATION OF DEVICENAMEADDRESSNAMEADDRESS