III. FACILITY EXIT LOCATIONS
(USING A COPY OF THE FACILITY SKETCH [LIC 999] INDICATE EXITS BY NUMBER)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EMERGENCY DISASTER PLAN FOR
CHILD CARE CENTERS
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
SIGNATURE
NAME(S) OF STAFF
TITLE ASSIGNMENT
DATE
ADMINISTRATOR OF FACILITY
TELEPHONE NUMBERFACILITY ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)
( )
( )
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.
1.
2.
3.
4.
5.
6.
1.
3.
2.
4.
DIRECT EVACUATION AND PERSON COUNT
HANDLE FIRST AID
TELEPHONE EMERGENCY NUMBERS
TRANSPORTATION
OTHER (DESCRIBE)
I. ASSIGNMENTS DURING AN EMERGENCY (USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED)
VIII. AFFIRMATION STATEMENT
II. EMERGENCY NAMES AND TELEPHONE NUMBERS
(IN ADDITION TO 9-1-1)
IV. TEMPORARY RELOCATION SITE(S)
(IF AVAILABLE, SUBMIT LETTER OF PERMISSION FROM RENTER/LEASSOR/MANAGER/PROPERTY OWNER)
VI. FIRST AID KIT (LOCATION)
V. UTILITY SHUT—OFF LOCATIONS
(INDICATE LOCATION(S) ON THE FACILITY SKETCH [LIC 999])
VII. EQUIPMENT
POLICE OR SHERIFF
RED CROSS
HOSPITAL(S)
CHILD PROTECTIVE SERVICES
ELECTRICITY
WATER
GAS
LIC 610 (10/03) (PUBLIC)
OFFICE OF EMERGENCY SERVICES
POISON CONTROL
OTHER AGENCY/PERSON
TELEPHONE NUMBER
TELEPHONE NUMBER
( )
SMOKE DETECTOR LOCATION (IF REQUIRED)
FIRE EXTINGUISHER LOCATION (IF REQUIRED)
TYPE OF FIRE ALARM SOUNDING DEVICE (IF REQUIRED)
LOCATION OF DEVICE
NAME ADDRESS
NAME ADDRESS
