How to Complete the LIC 610E: Emergency Disaster Plan for Elderly Facilities

The LIC 610E emergency disaster plan is the standardized form every licensed Residential Care Facility for the Elderly (RCFE) in California must complete, post on site, and file with the Community Care Licensing Division (CCLD) of the California Department of Social Services. It is required under Health and Safety Code section 1569.695, which lists what the plan has to cover, from evacuation routes to a 72-hour self-reliance strategy during a utility failure.¹ New applicants submit it with the initial license application; existing facilities keep one on file at all times and review it every year.

Where to Download the Form

The LIC 610E is a fillable PDF available from the CDSS Forms and Publications page under the “I–L” alphabetical listing. You can type into it on screen or print it and complete it by hand.² Pull two other documents at the same time:

Form LIC 999, the facility sketch or floor plan. Several LIC 610E sections cross-reference it, because assembly points and utility shut-off locations have to be marked on that sketch.³
Form LIC 610E-S, the Supplemental Emergency Disaster Plan, which covers the operational detail (backup power, medication storage, communication). Plan on completing it alongside the main form.

What to Gather Before You Start

The form asks for information you will not have memorized. Having it ready prevents blank fields, which are a common reason CCLD sends plans back for revision.

Facility identification: your RCFE license number (or application number for new applicants) and the facility’s full street address.
Emergency contact numbers: local fire, police, ambulance, Poison Control (1-800-222-1222), your CCLD regional analyst, the local long-term care ombudsman, any transportation providers you plan to use, and any hospice agency serving a current resident. The regulations specifically require notifying a resident’s hospice provider during an evacuation or relocation.⁴
Two relocation sites that can house your residents during an evacuation. One site must be outside the immediate area of your facility, not just a building next door, so a localized disaster does not take out your backup. Written permission letters from each site owner can be attached.²
Utility shut-off locations. Walk the building and note where the gas valve, water main, electrical breaker panel, and sewer cleanout actually are.
A current resident roster with dates of birth. The roster travels with staff during an evacuation for headcount purposes.
A staff roster showing names and titles of everyone who will be assigned a specific emergency duty.

Filling Out the LIC 610E Section by Section

Fill every section. A blank field reads as a scenario the facility has not planned for, which is exactly what a licensing analyst flags.

Facility Information and Emergency Contacts

Enter the facility name, license number, address, and the name of the licensee or administrator at the top. In the emergency telephone section, list numbers beyond 911: fire, police, ambulance, Poison Control, your local CCLD office, the ombudsman, transportation providers, and any hospice agency.¹

Evacuation Procedures and Assembly Points

Describe how staff will move residents out of each area of the building and where everyone will gather once outside. The assembly point also has to appear on the LIC 999 sketch.¹ Spell out how non-ambulatory residents and wheelchair users will get out, because the statute requires the plan to address residents with special mobility or medical needs. Mark every exit on the sketch and note which exits are wheelchair-accessible.

Staff Assignments

The form has a table where you assign a named staff member and title to each emergency task. Typical roles include:

Direct evacuation and person count: leading residents to the assembly point and confirming everyone is accounted for.
Utility shut-off and backup generator: reaching the shut-off valves and, if applicable, starting a generator.
Transportation: driving the facility vehicle or coordinating with an outside provider. If the plan relies on a facility-owned vehicle, the statute requires keys to be available to staff on every shift.¹
Resident supervision during the evacuation or after relocation.
Emergency communications: contacting 911, CCLD, families or responsible parties, hospice providers, and the ombudsman.
Retrieving stored food, water, medications, and first aid supplies.

Every assignment needs at least one staff name. If your facility runs multiple shifts, make sure each shift has someone assigned to every role. A plan that works only during the day shift is not a complete plan.

Temporary Relocation Sites

Enter the name, address, and contact information for each of your two shelter locations. One can be nearby, such as a church, community center, or neighboring facility, but the second must sit outside the immediate area.² Both should be equipped to shelter elderly residents safely: wheelchair access, beds, and bathroom facilities. Attach the written permission letter from each site owner if you have it.

Utility Shut-Off Locations

The form lists each utility type (electricity, gas, water, sewer, and “other”) with columns for the shut-off location and step-by-step instructions.² “In the garage” is not enough. Write it so that a new staff member who has never done it could follow the instructions during an actual emergency: “gray metal box on the north wall of the utility room, three feet left of the water heater, flip main breaker to OFF.” Mark each location on the LIC 999 sketch too.

What the Supplemental LIC 610E-S Covers

The LIC 610E-S picks up where the main form stops and covers the operational detail required by section 1569.695:¹

72-hour self-reliance: how the facility will feed, hydrate, and shelter residents for three full days without outside help, including during a complete power failure. If you plan to shelter in place without one or more utilities, explain the alternative resources on hand (stored water, non-perishable food, portable sanitation).
Emergency power: identify your backup generator, permanent or portable, or your arrangements with a supplier. For a permanent generator, note its location and how to operate it. For a portable unit, keep the manufacturer’s instructions with the plan.
Inoperable call buttons: how staff will respond to individual resident needs when the electronic call system is down, through increased rounds, a manual bell system, or another workaround.
Communication: your primary method of reaching residents, families, hospice providers, and the ombudsman, plus a backup method in case the first fails.
Medications: administration during disrupted conditions, and storage of medications that require refrigeration.
Assistive medical devices: how you will keep powered equipment such as oxygen concentrators or electric wheelchairs running, or provide alternatives.
Residents with special needs: identify residents on hospice care or with other heightened needs and how you will meet those needs.

Write in plain, concrete language. “Staff will place ice packs from the basement freezer into cooler A to keep insulin refrigerated” is more useful than “Medications will be properly stored.” Both the analyst reviewing the plan and the staff reading it at 2 a.m. during an earthquake need instructions they can follow without interpretation.

Where to Post It and Where to File It

Once both forms are complete, three things happen with the plan:

Post a copy at the facility in a prominent location near a telephone, so staff can reach it quickly.²
Return a copy to your Adult and Senior Care regional office within the CCLD. The main CCLD page links to a directory of Adult and Senior Care offices organized by county. Confirm your analyst’s preferred submission method; most offices accept mailed copies, and some accept documents through a secure portal or by fax.⁵
Make it available on request to residents, any responsible party for a resident, the local long-term care ombudsman, and local emergency responders.

New applicants submit the completed plan as part of the initial license application under Health and Safety Code section 1569.15.¹ Already-licensed facilities updating the plan send the revised version to the same regional office. Keep the resident roster portion confidential; the form notes that resident information must be handled under the record confidentiality requirements of Title 22, section 87506.

Annual Review and Updates

The plan is not a file-and-forget document. The licensee or administrator must review it at least once a year, update it as necessary, and sign and date the form to certify the review happened.² Certain changes trigger an immediate update:

Staffing changes. If a staff member assigned to an emergency role leaves, name a replacement right away. A plan that lists a departed employee as evacuation lead is a plan with a gap.
Layout or structural changes. Adding a room, sealing an exit, or reconfiguring common areas means your evacuation routes and facility sketch may no longer be accurate. Update both the LIC 610E and the LIC 999.
A change of relocation site. If one of your two shelter locations closes or becomes unavailable, document a new site before the next emergency.
Resident population changes. A new resident who uses oxygen equipment or receives hospice care changes the procedures in your special-needs and medical-device sections.

After each update, post the revised version at the facility and send a copy to your regional office. Hold on to superseded versions as well; during an inspection, an analyst may want to see the revision history.

What Happens If the Plan Is Missing or Incomplete

An incomplete or missing emergency plan can draw civil penalties under Health and Safety Code section 1569.49. A standard uncorrected deficiency runs $100 per day, with escalating amounts for repeat and serious violations, and much larger fixed penalties where resident injury, abuse, or death is involved.⁶ The daily figures add up quickly, and a pattern of emergency-plan deficiencies factors into licensing decisions, which can put a renewal at risk. Completing the LIC 610E carefully the first time and keeping it current is far cheaper than responding to a citation.

1
California Legislative Information. California Health and Safety Code 1569.695
2
California Department of Social Services. LIC 610E Emergency and Disaster Plan for Residential Care Facilities for the Elderly
3
California Department of Social Services. LIC 999 Facility Sketch (Floor Plan)
4
Legal Information Institute. California Code of Regulations Title 22 Section 87212 – Emergency Disaster Plan
5
California Department of Social Services. Community Care Licensing
6
California Legislative Information. California Health and Safety Code 1569.49