Fillable FACILITY SKETCH (Floor Plan) (California)

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FACILITY SKETCH (Floor Plan) (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITY SKETCH (Floor Plan)
Applicants are required to provide a sketch of the floor plan of the home or facility and outside yard. The floor sketch must label rooms
such as the kitchen, bath, living room, etc. Circle the names of the rooms that will be used by staff/residents/clients/children. Door and
window exits from the rooms must be shown in case of an emergency (see Emergency Disaster Plan). Show room sizes (e.g. 8.5 x
12). Keep close to scale. Use the space below. See back for yard sketch.
FACILITY NAME: ADDRESS:
LIC 999 (3/99)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FACILITY SKETCH (Yard)
The yard sketch should show all buildings in the yard including the home (with no detail), garage and storage building.
Include walks, driveways, play area, fences, gates. Show any potential hazardous area such as pools, garbage storage,
animal pens, etc. Show the overall yard size. Try to keep the sizes close to scale. Use the space below.
FACILITY NAME: ADDRESS:
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FACILITY SKETCH (Floor Plan) (California)

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Completed 10 April 2021

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