Form Lic 610e-S - Supplemental Emergency Disaster Plan For Residential Care Facilities For The Elderly
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2State of California – Health and Human Services Agency
California Department of Social Services
SUPPLEMENTAL EMERGENCY DISASTER PLAN
FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
INSTRUCTIONS:
Make available to emergency responders, and upon request, to residents onsite. Information should
be up to date at all times. Licensee may post a copy, with the LIC 610E, in a prominent location in
facility, near telephone.
Name Of Facility
Administrator Of Facility
Street Address
City
State
Zip Code
Telephone Number
Fax Number
Cell Phone Number
I.
FACILITY STAFF WILL OBSERVE THE FOLLOWING EVACUATION PROCEDURES:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Note: If evacuation location is on-site, licensee may include location(s) on Facility Sketch (LIC 999).
II. IF EVACUATING, FACILITY STAFF WILL ARRANGE FOR TRANSPORTATION, INCLUDING
COMMUNICATING WITH EMERGENCY PERSONNEL AND ACCESSING INFORMATION
NECESSARY TO CHECK THE EMERGENCY ROUTES, IN THE FOLLOWING WAYS:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
III. FACILITY STAFF WILL PREPARE 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 LONG-TERM POWER FAILURE, IN THE FOLLOWING
WAYS:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Note: Licensee may include location of emergency supplies on Facility Sketch (LIC 999).
LIC 610E-S (9/17)
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