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Home My WebLink AboutBUSINESS PLAN 8/6/2003Hazardous Materials/HazardOus Waste Unified Permit CONDITIONS OF ~PERMIT ON REVERSE SIDE.'. Permit ID#:: 015-000-000210 BEVERLY MANOR CONVALE: LOCATION: 3601 SAN DIMAS ST · This' i~ermit is issued for the followirm_: [] Hazardous Materials Plan r'l Underground Storage of H~,-rdOus Materials [3 Risk Management Program n Hazardous Waste On-Site Treatment IELD ' Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES' 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: Expiration Date: Of tic~'('' Ralpl~e of EvCY:~ · 'June 30; 2003 Issue Date Bakersfield Fire Dept. PREVENTION SERVICES 1715 Chester Ave. Bakersfield, CA 93301 Itt conformity with provisions of pertinent ordinances, codes and/or regulations application is made by: (Name of Company) (Address) to display, store, install, use, operate, sell or handle materials or processes'involving or creating conditions deemed ha=ardous to life or property as follows: Co,,nF'rZ.~.cSC-¢'~ ~ /_.~(~u,c~ 0~~ (r~oT-tO C-~o :~(z~ co ~'~. Permit FD 1952 ~lssued THIS PERMIT MUST BE POSTED (Date) (Fire Marshal) Card Gopy to Permitee fo~ Display Hazardous Materials/Hazardous Waste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE ..... ~,,~,,~,~,~,ii~,,;i~!ilr~?.i~V!ii:~,~y,!!i~,~,~" This permit is issued for the following: ' · ~,ii~"~?'~'~ ~?d21,¢iZ;~:::',~::;i~;,:::;Zdi~::::'~/?~J~Hazardous Materials Plan .... ¢i¢¥i:J!:~, ::':~"'"'~:~:::iiiiiiiiiiiil;,~. ~i!i ii i;;::~:iiiiiiiii~ii~"~e[ground Storage of Hazardous Materials PERMIT ID# 015-O214)00210 =/i~?[ ~,i;,:!!i;iiiiiiiii!ii!i ii:'" .~,!!!?'!iii!i[!!!ii~:!iii!i! !!,!!!!!:: iiiiiiiiii~!!i~];~kli~oagement Program Waste LOCATION 3601 SAN D I MA~,,,,'-,,,;'~ ~',~;~,~,, ~ -'.."~ ~ ~. ~" "~¢'"'~*'"~' '"=" ~" ~ "t+ .h ".. h r '~.--, ~..~. 'NZk ",_ '.;,...",,.4,L¢ ~ ,. % ',,,;4' Issued by: Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor B~kersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326.0576 Approved by: Expiration Date: ~t~ph Huey~ Office of i~we~fliiental ServiCes June 30, 2000 MISCELLANEOUS RECEIVABLES ADJUSTMENT NEWACCOUNT ~ ADDRESS CHANGE CLOSE ACCT j 'FINANCE CHARGE OTHER ADJ ,/ CUSTOMER NAME MAILING ADDRESS ZIP CODE SITE ADDRESS PARCEL NUMBER OF APPUCA~LE) ADJUSTMENT CHG DATE CHARGE CODE ADJUSTMENT AMOUNT REMARKS: '~'~ ~,,~~' / APPROVED E/FAC ILI TY FORM $ SCALE: BUSINESS N~%ME: DATE: ~/7/~7 FACILITY Ngwee: ' (CHECK ONE) SITE DIAGRkM / NORTH FLOOR: OF UNIT ~ ?: OF FACILITY DIAGR.~M ~ ~ (Inspector's Comments): -OFFICIAL USE ONLY- - SA - · /.2 IO4- j J (to e~i4- doorS) FLOOR Bakersfield, California .~ O~ P.T. ACT. ' lO(, i- 1-o'1: ~'Pcke~ i4ol Floor' BEVERLY MANOR CONVALE~NT HOSP Manager : Location: 3601 SAN DIMAS ST Ci~ty : BAKERSFIELD CommCode: BAKERSFIELD STATION 04 EPA Numb: SiteID: 015-021-000210 BusPhone: (661) 323-2894 Map : 103 CommHaz : Low Grid: 19B FacUnits: 1 AOV: SIC Code:8051 DunnBrad: Emergency Contact / Title ~ ~f;t~6B.~/ ADMINISTRATOR Business Phone: (661) 323-2894x 24-Hour Phone : (661) ~x~ Pager Phone : (~1) ~q-$~x Emergency Contact PETE LOPEZ Business Phone: 24-Hour Phone : Pager Phone : / Title / MAINTENANCE SUP 661) 323-2894x 661) 325-3624x 661) 337-1026x Hazmat Hazards: Fire Press ImmHlth Contact : ~i~ .~z~ MailAddr: 3601 SAN DIMAS ST City : BAKERSFIELD Owner BEVERLY ENTERPRISES Address : ONE THOUSAND BEVERLY WAY City : FORTSMITH Phone: 661) 323-2894x State: CA Zip : 93301 Phone: State: AK Zip : 72919 Period : Preparer: Certif'd: ParcelNo: to TotalASTs: = TotalUSTs: = RSs: No Gal Gal Emergency Directives: l, ~. Do hereby certify that I have rewiewsd the attached hazardous materJa!s manage- mer, t plan for_~¢__~ ~~ane mat it along with any ~e~ions constitute a complete and corre~ man- agement plan for my facility. -1- 07/15/2003 BEVERLY MANOR CONVALESCENT HOS~,]~]7~,/~~ SiteID: 215-000-000210 I dUL17?nnn I Manager : I > ..... BqsPhone: (805) 323-2894 Location: 3601 SAN DIMAS ST J'~V. M~p : 103 CommHaz : Low City : BAKERSFIELD ' .... G~id: 19B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 04 EPA Numb: SIC Code:8051 DunnBrad: Emergency Contact / Title ~ ~ 1)~u / ADMINISTRATOR Business Phone: (o~=~, ~ 2 ..... 24-Hour Phone : (o~} 932 Pager Phone : (&&[) $~ - J&~ x Emergency Contact~,...~/ Title ~ECiL ~CWHO~TEP~~ MAINTENANCE SUP Business Phone: (~05) 323-2894x 24-Hour Phone : (805) 366-~"31~-$$l- Pager Phone : (~/) Hazmat Hazards: Fire Press ImmHlth Contact : MailAddr: 3601 SAN DIMAS ST City : BAKERSFIELD Phone: ( ) State: CA Zip : 93301 x Owner BEVERLY ENTERPRISES ~¢~5d~ ~/~O~y Phone: , ........... Address : =~5- CE~[TP3~ SHC~PI~C CE~[TER State: ~5~ City : FORTSMITH~ A~~ Zip :~ 7~/q Period : to TotalASTs: = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No Emergency Directives: = Hazmat Inventory --As Designated Order Hazmat Common Name... ISpecHaz EPA HazardsI OXYGEN ,. Ha.~b4rtFcx.OLz~/ .... Do hereby certif~ t~at I t~ve (TyI:~ or print na~) reviewed the a~ached h~ardous materials man~e- mere plan ~or ~ ~ ..~nd ~hat it along with any ~rrecfions constitute a complete and corre~ man- agement plan for my facility. One Unified List Ail Materials at Site Frm I DailyMax Unit MCP 1686.00 FT3 Low -1- 06/13/2000 BEVERLY MANOR CONVALESCENT HOSP SiteID: 215-000-000210 ~ Inventory Item 0001 Facility Unit: Fixed Containers on Site ~lVflVi~ ~Vl~ / ~ ~./.-~.LJ ~vlG OXYGEN Days On Site 365 Location within this Facility Unit Map: Grid: OXYGEN ROOM ~ FRONT INSIDE CAS# ~O~19~ 7782-44-7 STATE ~ TYPE Gas /Pure PRESSURE TEMPERATURE I Above Ambient I Ambient CONTAINER TYPE PORT. PRESS. CYLINDER Largest ContainerFT3 AMOUNTS AT THIS LOCATION Daily Maximum. 1686.00 FT3 Daily Average 1400.00 FT3 %Wt. 100.00 HAZARDOUS COMPONENTS Oxygen, Compressed TSecret No I oRSIBi°Haz N No HAZARD ASSESSMENTS Radioactive/Amount EPA Hazards No/ Curies F P IH NFPA /// IUSDOT# MCP, I Low -2- 06/13/2000 BEVERLY MANOR CONVALESCENT HOSP SiteID: 215-000-000210 Fast Format = Notif./Evacuation/Medical --Agency Notification CALL 911 Overall Site 03/25/1992 Employee Notif./Evacuation SAME AS.#3 BELOW. 03/25/1992 Public Noti~./Evacuation 03/25/1992 EVACUATION PLAN LOCATED THROUGHOUT FACILITY INCLUDES EVACUATION ROUTE LOCATION OF FIRE ALARMS, FIRE EXTINGUISHERS, EMERGENCY, 9-1-1 ALL EMERGENCY SHUT OFF VALVES, FIRE DOORS, FIRE ALARMS/PANEL, OXYGEN STORAGE AND SHUT OFF, EMERGENCY STORAGE SPACE. EVACUATION IS TO BEGIN WITH PERSON EXPOSED TO MOST IMMEDIATE DANGER. INFORM OTHER STAFF AND FIRE DEPT. AMBULATORY PATIENTS TO EVACUATE FIRST AND NONAMBULATORY AND WHEELCHAIR PAITIENTS SECOND. EVACUATED PERSONS MUST TRAVEL AWAY FROM THE DIRECTION OF THE FIRE TO ANOTHER SECTION OF THE BLDG BEYOND THE FIRE. EVACUATION: PATIENTS TO BE EVACUATED USE BEDS, WHEELCHAIRS, BLANKET DRAG - RESIDENTS THROUGH NEAREST EXIT OUT TO PARKING LOT AND COVER WITH A BLANKET - DO NOT LEAVE UNATTENDED - MEDICAL FACILITIES IN AREA TO BE NOTIFIED OF EVACUATION AND THAT RESIDENCE WILL BE DIRECTED TO THEM - SCHOOLS MAY ALSO BE CONTACTED TO RECEIVE EVACUATED RESIDENCE. MEDICAL RECORDS WILL BE KEPT UP TO DATE. * IN CASE OF MAJOR EXTERNAL DISASTER MANY DECISIONS MAY BE MADE BY OUT LOCAL AUTHORITIES. Emergency Medical Plan 03/25/1992 WE ARE A SKILLED NURSING FACILITY WHO HAS TRANSFER AGREEMENTS WITH GREATER BAKERSFIELD MEMORIAL HOSPITAL, SAN JOAQUIN HOSPITAL, KERN VALLEY HOSPITAL, KERN MEDICAL CENTER, WESTSIDE DISTRICT HOSPITAL, NORTH KERN HOSPITAL.- WE ALSO KEEP A LIST OF EMERGENCY PHYSICIANS AT EACH OF OUR 2 NURSING STATIONS AND EMERGENCY AND DISASTER MANUAL. MEMORIAL HOSPITAL - 420- 34TH ST --B~i. ~- ~D- MERCY HOSPITAL - 2215 TRUXTUN AV - 327-3371. -3- 06/13/2000 BEVERLY MANOR CONVALESCENT HOSP SiteID: 215-000-000210 Fast Format = Mitigation/Prevent/Abatemt --Release Prevention Overall Site 03/25/1992 OXYGEN TANKS CHAINED IN A LOCKED CLOSET. NO SMOKING OXYGEN IN USE SIGNS PLACED IN ALL ROOMS WHERE OXYGEN IS USED. SPECIFIC FIRE PROCEDURES IN CASE OF EMERGENCY PROCEDURES DUE TO FIRE IN BUILDING. STAFF INSERVICED IN THESE EMERGENCIES. INFECTIOUS WASTE CONTAINED ON TREATMENT CART AT END OF SHIFT DOUBLE BAGGED AND TAKEN TO METAL STORAGE CONTAINER PROVIDED BY ENVIRONMENTAL SECURITY DISPOSAL TO BE DISPOSED OF IN A PROPER MANNER. PEOPLE HANDLING INFECTIOUS WASTE ARE INSERVICED ON PROPER HANDLING PROCEDURES'. --Release Containment 03/25/1992 FACILITY WILL TRY TO SHUT OFF VALVES SO THAT LEAKS ARE CONTAINED AND EMERGENCY HELP WILL BE REQUESTED BY DIALING 9-1-1. -- Clean Up 03/25/1992 THE AREA WILL BE AIREATED TO CLEAN UP THE VICINITY OF THE PROBLEM. Other Resource Activation -4- 06/13/2000 BEVERLY MANOR CONVALESCENT HOSP SiteID: .215-000-000210 Fast FOrmat Site Emergency Factors Special Hazards Overall Site --Utility Shut-Offs A) GAS - NORTHWEST CORNER OF BUILDING OUTSIDE B) ELECTRICAL - BACK NORTH MIDDLE OF BUILDING INSIDE C) WATER - BACK NORTH MIDDLE OF BUILDING INSIDE BUILDING D) SPECIAL - NONE E) LOCK BOX - NO 01/07/1990 -- Fire Protec./Avail. Water 01/07/1990 PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, FIRE EXTINGUISHERS THROUGHOUT FACILITY, ALARM SYSTEM THROUGHOUT FACILITY, ALL EMPLOYEES INSERVICED ON PROPER PROCEDURES TO RESPOND TO FIRE EMERGENCY. FIRE HYDRANT - NORTHEAST CORNER IN FRONT OF BUILDING SITE ON PROPERTY LINE Building Occupancy Level -5- 06/13/2000 BEVERLY MANOR CONVALESCENT HOSP SiteID: 215-000-000210 Fast Format Training -- Employee Training WE HAVE 110 EMPLOYEES AT THIS FACILITY. WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE. INSERVICE ON HAZARDOUS MATERIALS IN BUILDING HELD TWICE A YEAR. BY DIRECTOR OF STAFF DEVELOPMENT. WILL COVER TOPICS OF: 1) OXYGEN (HANDLING OF, AND STORAGE OF) 2) INFECTIOUS WASTE (HANDLING OF AND STORAGE OF) 3) EVACUATION PROCEDURES IN CASE OF EMERGENCY Overall Site 03/25/1992 CONDUCTED -- Page 2 Held for Future Use Held for Future Use 6 06/13/'2000 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 215-000-00 Overall Site with 1 Fac. Unit General Information Location: 3601 SAN DIMAS ST Community: BAKERSFIELD STATION 04 Flu I Map: 103 -~---;.-,',',:--: 'r,~,w .... - I Grid: 19B F/U: 1 AOV:' 0.0 Contact Name Title I Business Phone I 24-Hour Phoneq MARILYN FOWLER ~d,mi~o~ (805) 323-2894 x (805) 833-0333~ CECIL MCWHORTER ~D~4q~gt~.,54~£~ F'(805)1 323-2894 x I (805) 366-3531/ Administrative Data Mail Addrs: 3601 SAN DIMAS ST D&B Number: City: BAKERSFIELD State: CA Zip: 93301- Comm Code: 215-004 BAKERSFIELD STATION 04 SIC Code: 8051 Owner: BEVERLY ENTERPRISES "Phone: [.~..~; ):~.~.2-,'~"//~. Address: ~-75 5 FAiKOAi~S AV il5~ ~~ 5~,n~a~r- State: ~r~S ~9o5 Zip: Sugary I, J4axi t~,a H. i~ote.¢- Do hereby certity that I have reviewed the ~',--ha4 h~vnrd,~U$ . ~,,'...' .......................... materials manage. meat pre,', ':,. ~... ~ N~ ........ ;:.'~d that it ~ong wRh any ....... ,"-. ,- ~v,,:-~,., .... , :,;qs~h-~:t3 a complete and ~rr~ man- ~ement plan Cot my ~acili~. 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 215-000-000210 02 - Fixed Containers on Site Hazmat Inventory Detail in Reference Number Order Page 02-001 OXYGEN ~ Fire, 'Pressure, Immed Hlth Gas 1686 Low FT3 CAS #: .7782-44-7. Trade Secret: No Form: Gas Type: Pure Days: 365 Use: MEDICAL AID OR PROCESS Daily Max FT3 1,686 Daily Average FT3 1,400.00 Annual Amount FT3 16,800.00 Storage PORT. PRESS. CYLINDER Press T Temp Location Iabove IAmbientlOXYGEN ROOM SOUTHEAST FRONT INSI -- Conc 100.0% Oxygen, Compressed MCP i..-List Components 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 215-000-000210 00 - Overall Site <D> Notif./Evacuation/Medical Page <1> Agency Notification CALL 9'11 <2> Employee Notif./Evacuation MEMORIAL HOSPITAL 420 34TH ST 327-1792 MERCY HOSPITAL 2215 TRUXTUN AV 327-3371 <3> Public Notif./Evacuation NONE LISTED- ~% O~ ~OJ~ -. o°_ - -- .- ~ o~ <4> Emergency'Medical Plan WE ARE A SKILLED NURSING FACILITY WHO HAS TRANSFER AGREEMENTS WITH GREATER BAKERSFIELD MEMORIAL HOSPITAL, SAN JOAQUIN HOSPITAL, KERN VALLEY HOSPITAL, KERN MEDICAL CENTER, WESTSIDE DISTRICT HOSPITAL, NORTH KER~ HOSPITAL. WE ALSO KEEP A LIST OF EMERGENCY PHYSICIANS AT EACH OF OUR 2 NURSING STATIONS AND EMERGENCY AND DISASTER MANUAL. 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 215-000-000210 Page 4 00 - Overall Site <E> Mitigation/Prevent/Abatemt <1> Release Prevention OXYGEN TANKS CHAINED IN A LOCKED CLOSET. NO SMOKING OXYGEN IN USE SIGNS PLACED IN ALL ROOMS WHERE OXYGEN IS USED. SPECIFIC FIRE PROCEDURES IN CASE OF EMERGENCY PROCEDURES DUE TO FIRE IN BUILDING. STAFF INSERVICED IN THESE EMERGENCIES. INFECTIOUS.WASTE CONTAINED ON TREATMENT CART AT END OF SHIFT DLOUBLEBAGGED AND TAKEN TO METAL STORAGE CONTAINER BY--~RTt~?--~m~,~o~~~ PROVIDED TO BE DISPOSED OF IN A PROPER MANNER. PEOPLE HANDLING INFECTIOUS~"~ WASTE ARE INSERVICED ON PROPER HANDLING PROCEDURES. <2> Release Containment <3> Clean Up <4>'Other Resource Activation . 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 215-000-000210 00 - Overall Site <F> Site Emergency Factors Page 5 <1> Special Hazards <2> Utility Shut-Offs A) GAS - NORTHWEST CORNER OF BUILDING OUTSIDE B) ELECTRICAL - BACK NORTH MIDDLE OF BUILDING INSIDE C) WATER - BACK NORTH MIDDLE OF BUILDING INSIDE BUILDING D) SPECIAL - NONE E) LOCK BOX - NO <3> Fire Protec./Avail. Water PRIVATE FIRE PROTECTION - SPRINKLER SYSTEM THROUGHOUT FACILITY, FIRE EXTINGUISHERS THROUGHOUT FACILITY, ALARM SYSTEM THROUGHOUT FACILITY, ALL EMPLOYEES INSERVICED ON PROPER PROCEDURES TO RESPOND TO FIRE EMERGENCY. FIRE HYDRANT - NORTHEAST CORNER IN FRONT OF BUILDING SITE ON PROPERTY LINE <4> Building Occupancy Level 02/24/92 BEVERLY MANOR CONVALESCENT HOSP 00 - Overall Site <G> Training 215-000-000210 Page <1> Page l~,.~x. WE HAVE ??. EMPLOYEES AT THIS FACILITY WE HAVE MATERIAL SAFETY DATA SHEETS ON FILE INSERVICE ON HAZARDOUS MATERIALS IN BUILDING HELD TWICE A YEAR. BY DIRECTOR OF STAFF DEVELOPMENT. WILL COVER TOPICS OF: 1) OXYGEN (HANDLING OF, AND STORAGE OF) 2)~ INFECTIOUS WASTE (HANDLING OF AND STORAGE OF) 3) EVACUATION PROCEDURES IN CASE OF EMERGENCY CONDUCTED <2> Page 2 as needed <3> Held for Future Use <4> Held for Future use CITY of BAKERSFIELD "W£ CARE" e RECEIVED ~~ ~(?~U~ ,, FEB 1 ~ 19a9 (ty~e or nrin: name) HAZ. MAT..OIV. RECEIVED Do hereby certify that I have reviewed the attached Hazardous Ma~er'i=ls ~,~ine== Dian Ans'd (name of business) and that. it along with the attached additions or corrections constitute a comDlete and correct Business Plan for my facility. . . ~:~na:Ure- - _ date BUSINESS NAME BEVERLY MANOR CONVALESCENT HOSP LOCATION 3601 SAN DIMAS ST ID NUMBER 215-000-000210 HIGH HAZARD RATING 2 1 OV}E lq~V IIE W LAST CHANGE 12/17/87 BY EVAMC JURIS CODE 215-004 JURIS BAKERSFIELD STATION 04 MAP PAGE 103 GRID 19B FACILITY UNITS I HAZARD RATING 2 RESPONSE SUMMARY 2A SEC 4) A PERSON OF RESPONSIBILITY ON STAFF 24 HOURS A DAY - ADMINISTRATOR TO BE NOTIFIED. ALL EMPLOYEES ARE INSTRUCTED ON PROPER PROCEDURES OF RESPONSE IN ALL EMERGENCY AND DISASTER SITUATIONS. LIST OF EMERGENCY NUMBERS, PATIENT TRANSFER AGREEMENTS KEPT AT EACH NURSING, STATION AND IN DISASTER KIT. ALL EMPLOYEES INSERVICED IN PROPER PROCEDURES. EMERGENCY CONTACTS 2A SEC 2) MARILYN FOWLER 323-2894 OR 833-0333 ---)(~"~C~I ~Lb~o~:f~r" 323-2894 OR 366-965] UTILITY SHUTOFFS 2A SEC 3) A) GAS - NW CORNER OF BUILDING OUTSIDE B) ELECTRICAL - BACK NORTH MIDDLE OF BUILDING INSIDE C) WATER - BACK NORTH MIDDLE OF BUILDING INSIDE D) SPECIAL - NONE E) LOCK BOX - NO NOTIFICATION / PUBLIC EVACUAT ION LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > PAGE 1 12/14/88 09:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME BEVERLY MANOR CONVALESCENT HOSP LOCATION 3601 SAN DIMAS ST ID NUMBER 215-000-000210 HIGH HAZARD RATING 2 TRAINING SUMMARY LAST CHANGE / / BY < NO INFORMATION RECORDED FOR THIS SECTION > 4 . LOCAL EMERGENCY MEDICAL ASSISTANCE LAST CHANGE 12/17/87 BY EVAMC 2A SEC 5) WE ARE A SKILLED NURSING FACILITY WHO HAS TRANSFER AGREEMENTS WITH GREATER BAKERSFIELD MEMORIAL HOSPITAL, SAN JOAQUIN HOSPITAL, KERN VALLEY HOSPITAL, KERN MEDICAL CENTER, WESTSIDE DISTRICT HOSPITAL, NORTH KERN HOSPITAL. WE ALSO KEEP A LIST OF EMERGENCY PHYSICIANS AT EACH OF OUR 2 NURSING STATIONS AND EMERGENCY AND DISASTER MANUAL. PAGE 2 12/14/88 09:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME BEVERLY MANOR CONVALESCENT HOSP LOCATION 3601 SAN DIMAS ST FACILITY UNIT 01 ID NUMBER 215-000-000210 HIGH HAZARD RATING 2 OVERALL HAZARDOUS MATERIALS INVENTORY LAST CHANGE 12/17/87 BY EVAMC ID TYPE NAME LOCATION CONTAINMENT MAX AMT UNIT HAZARD USE PURE OXYGEN OXYGEN ROOM SE FRONT PORTABLE PRESS. CYL. ID PERCENT COMPONENTS 2359.00 100.0 OXYGEN, COMPRESSED 2248 FT3 HIGH MEDICAL AID OR PROCESS HAZARD LISTS HIGH PROTECT I ON / WATER SUPPLIES LAST CHANGE 12/17/87 BY EVAMC 3A SEC 4) SPRINKLER SYSTEM THROUGHOUT FACILITY FIRE EXTINGUISHERS THROUGHOUT FACILITY ALARM SYSTEM THROUGHOUT FACILITY ALL EMPLOYEES INSERVICED ON PROPER PROCEDURES TO RESPOND TO FIRE EMERGENCY. 3A SEC 5) NE CORNER IN FRONT OF BUILDING SITE ON PROPERTY LINE PAGE 3 12/14/88 09:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 BUSINESS NAME BEVERLY MANOR CONVALESCENT HOSP LOCATION 3601 SAN DIMAS ST ID NUMBER 215-000-000210 HIGH HAZARD RATING 2 n e EMPLOYEE NOT I F ICAT ION / EVACUAT ION LAST CHANGE 12/17/87 BY EVAMC 3A SEC 2) MEMORIAL HOSPITAL 420 34TH ST 327-1792 MERCY HOSPITAL 2215 TRUXTUN AV 327-3371 MITIGATION / PREVENT ION / ABATEMENT LAST CHANGE 12/17/87 BY EVAMC 3A SEC 1) OXYGEN TANKS CHAINED IN A LOCKED CLOSET. NO SMOKING OXYGEN IN USE SIGNS PLACED IN ALL ROOMS WHERE OXYGEN IS USED. SPECIFIC FIRE PROCEDURES IN CASE OF EMERGENCY PROCEDURES DUE TO FIRE IN BUILDING. STAFF INSERVICED IN THESE EMERGENCIES. INFECTIOUS WASTE CONTAINED ON TREATMENT CART AT END OF SHIFT DOUBLE BAGGED AND TAKEN TO METAL STORAGE CONTAINER PROVIDED BY PRICE DISPOSAL WHERE IT IS KEPT LOCKED UNTIL IT IS PICKED UP BY PRICE DISPOSAL TO BE DISPOSED OF IN A PROPER MANNER. PEOPLE HANDLING INFECTIOUS WASTE ARE INSERVICED ON PROPER HANDLING PROCEDURES. PAGE 4 12/14/88 09:51 MATERIAL SAFETY DATA SYSTEMS, INC. (805) 648-6800 CITY of BAKERSFIELD NON-- q.'RAI_)E SECRETS ' ~'g' .L_ of ..L BUSINESS NA~E: ~V~ ~~~~ ~ 9. O~NER NAME: j~~ ~.~ P~ NAME OF T~S FACILITY: j~ C-~ - ~ith of Pm~q /Ith , i Wt 13 k&C.l.S, iI (C~k all tMt ~lth of Pr~sure ~lth , I certify ~der wlty o( 1~ t~t I ~ve ~rsmillyexwin~ ~ N fNililr .tth t~ tnfor~tim su~itC~ In this ~ I11 IttKM ~wtl, ~ t~t ~s~ m W i~t~ Of t~l tMIvIMll m~libll lor obt~ininQ_t~ ifl~ptJm. I ~limve tMt ~ s)Witt~ infomtim is t~, Kcurlti, ~d c~litm. ,~ -~a7~.,~3~ - '" [']GI~ii~'F[~G~liIi;i Si)~ilG~i ................................................... ~l ~ ........................... A® VII. MISCELLANDOUS EMERGENCIES EXPLOSIONS TOXIC FUMES. TRAIN DERATT~S · BROKEN GAS MAINS AUTO/TRUCK COLLISION WITH FACILITY 1. 'Administrator/Charge Person Appraise situation and if necessary: (1) Follow procedure under "DISCOVERY OF FIRE" and C or D "ACTION" as appropriate. (2) Administer first .aid as needed. (3) If evacuation is deemed necessary, follow procedure under "EVACUATION". VIII-1 ae VIII. EVACUA~IQN The chain of COmmand during this action shall be the senior position of the following: AEMINISTRATOR DON CHARGE ~7JRS E STAFF MEMBER In the event of a fire, this command is relinquished to the local Fire Department officer upon arrival at the facility. Any disaster or emergency event which directly affects this facility will require a decision either to evacuate residents or not to evacuate residents. Therefore, evacuation becomes a prime'COn- sideration. There are three (3) types of evacuation and the severity of emergency determines which will be made. They are: i. INTERNAL (from one fire/smoke zone to another) ii. EXTERNAL (to the exterior) iii. EXTEN~,ED (to another location) If fire is on roof, .in attic, or if area is permeated with natural gas; the evacuation will always be external. The PRIORITY OF M~ shall be in the following 'order: .AMBUI2k%~RYRESID~ FIRST, WHEELCHAIRS AND WALKERS SECONDLY; AND LASTLY, BEDRIDDEN RESIDENTS who shall be removed by the following methods: Carry on bed linens with edges rolled as a stretcher, by two people, or dragged by one person. Never use the mattress. ii. Carried by one person using the "pack strap" or "hip" carry method. iii. Carried by two people using the "pack saddle" or "extremity" carry. SEE PAGE **** FOR INSTRUCTIONS oN CARRY METHODS. Internal Evacuation (wi~hlD~ d~ Rescue endangered residents from affected rooms, joining or adjacent rooms and, CLOSE THE DOORS as residents are moved to adjacent area or room of refuge within wing/zone. VIII-2 2. ~fove residents from. affected wing/zone to adjacent wing/zone, seeing that the fire/s~Dke doors remain closed when passing through them. 3. After all residents have been evacuated from affected wing/zone, incidental smoke passage can be further contained by placing wet linens/clothing around smoke passage area. 4. If fire continues uncontrolled, and there is inclement weather, ~ movement to another wing/zone should be made before exposing residents to harsh conditions outside. 5. If current medical records are endangered, they should be removed to a safe location as designated by Nursing or Administration. External Evacuation (on site) Assemble residents in an area not less than twenty (20) feet and upwind from the facility where staff members are assigned to prevent rerent/~y_ilkg the prem~ises. After residents are clear of the building, protection from. the elements and/or first aid is given as needed. If possible, provide residents with a diversion by dispensing drinks, cookies, etc., or perhaps advising them of the status of emergency and reassuring them that they are safe and being for. Extended Evacuation (to other location (s)~ ) This action is the last and least desirable of efforts and requires such preparation and pre-planning, that the memory cannot be trusted to carry out details in an orderly fashion. ~~ Dependent on the time element involved, and the speed needed in preparation, CHECKLISTS have been prepared for assistance in detailing functions for staff members and volunteers by depar~T, ents as follows. These CHECKLISTS should be copied for distribution. 1. PREPARATION Administrator/Administrative and Office Personnel Use the following and others as developed. Check List - 1 Check List - la Check List - lb Check List - lc be Director of N~rsing/Ch~_rge Nurse/Aides Use the following and others as developed. Check List - 2 Check List - 2a Check List - 2b Check List - 2c VIII-3 c. ~liD~_~o_~ se ke~ ng/Laund r y Use the follcwing and others as developed. Check List - 3 Check List - 3a Check List - 3b~ d. Dietary Use the following and others as. dispensed. Check List - 4 Implementation of Evacua~icn The extended evacuation of residents is the same as the "on site" evacuation but rather than stopping when getting outside, movement continues to the loading of residents in transportation~ vehicles, which will take them to ~ pre-determined location (See Evacuation Designations). a. A designated staff mmmber shall be assigned to each vehicle to accompany the residents for care and assurance. b. Medicines, medical records, medical supplies are to go with or at the sar~ time as residents as determined by nursing. c. Records, equipment, etc., are to follow later. d. After evacuation of building, use Check List 3b. Tn event of evacuation to other locations, to: VIII-4 residents will be taken (Name) (Address) (Phone) (Name) (Address) (Phone) ~JO (Name) (Address) (Phone) XI-2 CHECK LIST #la (For Administrative and/or Office Personnel) (Or Consultants on location) Items to be boxed for removal from facility to the Regional Office or a temporary safe place. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Resident financial records. Current employee personnel records. General Ledgers. Accounts payable invoices not yet processed. Policy and Procedure Manual Consultant Reports Manual. Incident/Accident Report M~nual. ,Survey Reports. e ® 6. 7. 8. 9. 10. xI-1 XI. CHECK LISTS CHECK LIST #i (For Administrative Staff) (As designated) Call in off-duty personnel as needed Arrange transportation, i.e., auto, ambulance and trucks for local; charter buses and rental trucks for distance travel. Notify receiving locations (Evacuation Designations) Confer with local hospitals for possible transfer of critical or injured residents/staff. Notify governing agencies ofplans. Box office records (Check List %la) Box valuable records (Check List ~lb) Distribute check lists for implementation. Notify families/responsible party for ambulatory residents to come for them. Assist in evacuation by helping other departments. CHECK LIST #lb (For A~ministrator Removal) When there is an EXTERNAL OR EXTENDED evacuation, the following items are to be removed with ~]irect responsibility of Administrat_or for safekDeping: 2. 3. 4. 5. 6. 7. 8. 9. Patient Trust Records Patient Trust petty cash. Facility ~etty ,cash. Census records Receipt books. Tin~ and Signature records. State License Administrator ' s current license. Health Care Plan books. · XI-4 CHECK LIST #lc ADMINISTRATQR -- Severe Weather WITH ADVANCE NOTICE OF SEVERE WEATHER, the following check list is to be utilized by the Administrator. The acquisition of any item(s) shall have prior approval of the Regional Man~ger. ® 3. 4. 5. 6. 7. 8. e 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 121. 22. Masking tape (for glass and identifying equipment) Mark-A-Lot Markers Plywood Flashlights Batteries Coleman lanterns - do not use kerosene for fuel Coleman stoves - do not use kerosene for fuel Fu. el supPly (for lanterns and stoves) - keep fuel supply at least 2Q feet away from building. Ice chests (nurse stations/transport) Water containers (facility use and tr.ansport) Garbage bags (heavy duty) (for l~tient clothes, -etc.) Wet vacuum Tools (~r, screwdriver, pliers, nails, crowbar) i Rubberbands (heavy) - for garbage bags Spot labels (self-sticking, 3 colors) (facility identification) Portable pot (for transport) Cardboard boxes (for records, charts, medications, etc. ) Distilled water Large roll heavy plastic sheeting (cover for broken windows) Heavy duty (commercial) stapler (for attaching plastic sheeting) Burlap bags/sand (for sandbagging) X1-5 CHECK LIST %2 (For Licensed Personnel) e ® ® Director of 'Nursing/Charge Nurse to ascertain that medical supplies, drugs (legend and non-legend) are identified and are available for immediate use. Director of Nursing/Charge Nurse to ascertain if Physicians are available and, at same time, obtain telephone physicians order .to evacuate residents to another location. · Combine medical records/charts, identify and pack for movement. Determine emergency oxygen supply is available. Determine that first-aid kits have full compliment of supplies and keep available for use. X!-6 CHECK LIST #2a NURSIN~ IN THE EVENT OF EVACUATION TO OTHER LOCJ%TIONS: Identify blind and/or deaf residents (per nursing policy). ~Communication cards for use with deaf patients are located at back cf this · anual. Indicate on room roster which facility each resident is to be sent to. Assign a color code to each receiving facility: Red Spot to - Facility I Yellow Spot to - Facility II Blue Spot to - Facility III, etc. Place a color spot on each resident's chart according to assigned facility. Put rubber band around chart. Box according to assigned desig- ~ nation. Bag individual ~resident medications in zip-lock, individual plastic bags and mark with matching color s~ot. Include any prosthetic devices and equipment that will be required. Box according to assigned designation. Pack liquids along side bags in box. Bag individual resident treatment supplies in zip-lock individual plastic bags and mark with matching color s~ot. Include any prosthetic devices and equipment that will be required. Box according to destination. Bag approximately three changes of clothing for each resident in a plastic garbage bag, write name on masking tape with Magic ~rker, label and color spot. e Box: Vendor drugs Souffle cups Med cups -Pill crusher 1 reed tray 4 cans (individual) orange juice with 2 sugar packets taped on top Small assortment of syringes Alcohol wipes Paper cups Alarm clock First aid kit Tongue blades Place in one box and label "DRUG RCOM SUPPLIES". 10. 11. CHECK LIST 92a (continued) Handi-wipes Urinals Bed pans Toilet paper Emesis basins Blood pressure cuff Stethoscope Gloves Safety pins Clinitest kit Place in one box and label "NURSE AIDE SUPPLIES" Diaper all incontinent and ~otentially incontinent residents. Tag each resident with cardboard mailing tab, including: Name of resident Special diets (ex., diabetic) Special instructions/warnings Color spot to indicate destination Pin these tags to the back of resident. XI-8 CHECK LIST %2b "for SENDIkK; FACILITY Disposable diapers Magic ~rker ~sking tape (wide) Garbage bags (plastic) Zip-lock plastic bags Color spots of identi- fication Arm bands Rubber bands Handi-Wipes 2 urinals 2 bed pans Cardboard boxes 1 med tray Souffle cups/reed cups Pillow/cases First aid kit Pill crusher Tongue blades Small orange juices with sugar pkts. attchd. Igloo water jug with water Toilet paper · Small assortmt. syringes Emergency 0 2/masks Battery operated radio Gloves Safety pins Jellies Clinitest Ki~ Paper cups Feeder syringes Cardboard mailing tags Blood pressure cuff Stethoscope Thermometer & cover Alcohol wipes Disposable diapers Magic Marker Foley catheters Foley trays Syringes (assorted) Med cups Souffle cups Papers cups Flashlights/batteries Distilled -water Masking tape(wide) CHECK LIST $2c for RECEIVING FACILI~i XI-9 CHECK LIST #3 MAIA~ENANCE / HOU S EF~ EP.I%~G/LAUNDRY. XI-10 At disaster '~Watch" and "Warning": e e 7. 8. 9. 10. 11. 12. 13. 14. 15. Be sure adequate supply of mops, buckets and cleaning equipment are on hand. Launder all soiled linens. Be sure adequate linen and blankets are available. Make sure wet-vac is operable. Apply masking tape to all glass to reduce breakage or shattering. Board glassed areas as necessary. Secure oxygen cylinders (chained and capped). Place al~ low stored supplies up higher and off floor. Secure or storeyard and grounds equipment. RemDve all loose items on premises, including trash cans, lumber, bricks, etc. Secure additional gasoline and ~uel, as requested. Check water level on battery systems (emergency lighting). Be sure dumpster lid is closed. Remove dead limbs from trees. Secure potable water, as directed by Administrator. XI-11 CHECK LIST #3a SEcuRn OF mE SmS _Upon total evacuation to other locations, the premises must be secured to prevent damage and theft. The following list should be helpful. 2. 3. 4. 5. 6. ® 12. 13. 14. 15. 16. 17. Tape all glass to reduce breakage or shattering. Disconnect the generator in event of power failure. Silence the alarm trouble signal in event of power failure. Shut off gas. Secure oxygen cylinders (chained and capped). Disconnect all electrical appliances and equil~nent (except freezer and refrigerator). Trip breakers to leave only minimal lighting (inside and outside). Place all records removed up and away from possible flooding. (file cabinets are not water-tight) Move furniture toward interior walls and away from windows. O~en or remove drapes/blinds. Determine that sewer clean-outs are capped. Lock all medication, supply and equipment room doors. Sand bag-entrance and exit doors. Lock all exit doors. Leave keys with police or employee not evacuating. Arrange with police, National Guard, or private guard to patrol the site. Determine that dumpster lids are closed. XI-11 CHECK LIST $3a SECURING OF PREMISES _Upon total evacuation to other locations, the premises must be secured to prevent damage and theft. The following list should be helpful. me 2. 3, 4. 6. ® 10. 11. 12. 13. 14. 15. 16. 17. Tape all glass to reduce breakage or shattering. Disconnect the generator in event of power failure. Silence the alarm trouble signal in event of power failure. Shut off gas. Secure oxygen cylinders (chained and capped). Disconnect all electrical appliances and equi~ent (except freezer and refrigerator). Trip breakers to leave only minimal lighting (inside and outsi de). Place all records removed up and away from possible flooding. (file cabinets are not water-tight) Move furniture toward interior walls and away from windows. Open or remOve drapes/blinds. Determine that-sewer clean-outs are capped. Lock all medication, supply and equipment roc~ doors. Sand bag entrance and exit doors. Lock all exit doors. Leave keys with police or employee not evacuating. Arrange with police, National Guard, or private guard to patrol the site. Determine that dumpster lids are closed. XI-12 5. 6. 7. 8. 9. 10. 11. CHECK LIST ~3b FOR Maintenance/Laundry and Housekeeping Personnel AFTER EVACUATION OF BUILDIb~S Shut down laundry equipment. Open dryer doors. Shut down HVAC systems. Shut down fire alarm system. Turn out all but emergency lighting. DO NOT disconnect electrical uti']ity power source. Disconnect generator battery. Turn all thermostats to off position. Remove supplies and equipment as directed. Assist in evacuation as directed. Secure all Windows/doors. xi-13 CHECK LIST DIETARY If evacuatioB by_ bus is necessary_, take only those food supplies which your residents and staff would consume during the trip. The only ~ items to take from Dietary Department include: Paper plates Plasticware Special food items that might not be available at receiving facility, i.e., Ensure, etc. Dietary roster and diet cards .... A minimum of two (2) dietary employees should be assigned to go with ~he residents to the evacuation site. The following food and supplies should be on hand at the receiving facility. These supplies should also be on hand in a facility which is in the disaster area, but is not evacuating. Canned luncheon meats TVP ham and chicken Cold cereals Jelly Graham crack'er or Vanilla wafers Applesauce .- Orange juice Beverage drink, instant Canned fruit juices Powdered milk Peanut butter Crackers Bread (order extra, if poss.) Canned fruits Tea/instant coffee Baby food (pureed diets) B. OTHER SUPPLIES Paper plates Paper cups (hot & cold) Paper bowls Plastic flatware Napkins Cleaning supplies Pap~.r towels Trash bags, plastic Sterno cans & racks Bleach Containers avail. for storage of drinking water If the facility is evacuated, throw out all refrigerated leftovers. FIRE AND DISASTER LiST EMERGENCY kVJMB E RS FIRE DEFT. POLICE DEFT. 324-4542 327-7111 324-6011 or 911 WATER DEPT. P G & E TELEPHONE SEWAGE PLUMBER ELECTRICIAN AIR COND. .327-4611 327-6011 325-1309 327-8668 399-5154 323-2818 DRUG SUPPLIES MEDICAL PHARMACY GREGG's PHARMACY 327-3956 327-9749 RENTAL E OJIPMENT MEDICAL PHARMACY 327-7524 HOPPER MEDICAL 861-7018 HEALTH MART-EMERGENCY E ~J IPMENT PROBLEM 327-1492 FOOD SUPPLY SMART AND FINAL LIBERTY FOODS LABORATORY MERIS LAB 327v7223 1-800-742-1661 -' 3~3-600~- '-.:. RADIOLOGY PORTABLE x-ray 325-8410 P~R~MACIST .- CLARK GUSTAFSON 327-~524 "CHURCHES CATHOLIC ''323'5009 BAPTIST 325-.t978 LUTHERAN 323-3355 METHODIST 832~8778 PREgBYTERIAN 325-9419 ~KEY PERSONNEL: Person on duty will be responsibl~ ~ntil relieved ADMINISTRATOR --MARILYN FOWLER OFFICE MANAGER --KATHY SCERRA 833-0333 (~q-qqqO DIRECTOR OF NURSES--CAROL MULHALL 871-7644 ASST DIRECTOR--DEANA MONTGOMERY 746-4166 POLICE DEPT. 327-7111 or 911 SHERIFF DEPT.327-3392 CIVIL DEFENSE 871-7301 HOSPITALS MEMORIAL 327-1792 MERCY 327-3371 SAN JOA~UIN 327-1711 I~MC 326-2000 BKSFD CO.MM HOSP 399-4461 MORTUARIES MISH PAYNE AND SONS GREENLAWN HILLCREST · 'OXYGEN HEALTH MART · .BLOOD~ RED CROSS 399-9391 ·324-9431 '324-9701 ·366-5766 '327~1492 ''324-6~27 ''AMB~NCE'SERVICE HALL 327-4111 GOLDEN k-MPIRE 327-9000 ''CO}tMITTEE'PHYSCIANS DR. LO~It~dm~coF~, ~ql-qSq~ DR. ARDELL "'871-1836 or 822-4402 ''MEDICAL'DIRECTOR DR. ARDELL ''871'1836 or 822-4402 IF UNABLE. TO CONTACT ATTEh~ING PHYSCIAN -- PLEASE CONTACT MEDICAL DIRECTOR TYPES OF DISASTERS:. 1.INTERNAL 2.EXTERNAL 3.DISASTER THREATS DURING INTERNAL DISASTER PATIENTS MAY BE EVACUATED TO MEMORLiL HOSPITAL Larry Chasson Beverly Manor 2715 Fresno St. Fresno, CA 93721 'we would'provide space in our living room, dining room and lobby to hold patients temporarily ~til more Dear Mr. Chasson, '.This letter is to verify that Beverly Manor Convalescent i. Hospital, located a,t 3601 San Dimas,Bakersfield,CA, ~ ,-..-.: ~. . - , will accept patients from your facility in the event of an emergency. ?:in ~he event you would require evacuat-ion we would Pt c°nvaleScent patients, not in an acute episode, of any type of illness, for admission to each and every empty bed available. In the event of extreme ~ergency adequate accomodations could be arranged. Sincerely, Jerome L. Sturz Administrator,.. Olive Marean Bakersfield Convalescent Hospital 730 34th St. Bakersfield,CA 93301 July 8, 1980 Dear Miss Marean, }I~-.?' .." This letter is to verify that Beverly Manor Convalescent .~{.-~,. ~.'..:.': .. .. -. . ~['i?i'~.'L.=~:i~f.~!'''.. Hospital, located at" 3601 San Dimas ,Bakersfield CA .... . , , ". will accept patients from your facility i'n the event- In the event you would require evacuation we. would accept convalescent patients, not in an acute episode, of any type of illness, for admission to each al~d every empty bed available. In the event of extreme emergency we would provide space in our living room,dining room and lobby to hold patients temporarily until more adequate accomodations could be arrang~-d. ~_"~). 34th Street · Bekersfield, Celifornia 93301 (805) 327-7687 August 7' 1980 Jerome L. Sturz Beverly Manor Convalescent Hospital 3601 8an Dimas Bakersfield ca 933ol Dear Mr. Sturz, This letter is to verify that Bakersfield Convalescent Hospital, located at ?30 3~th. Street, Bakersfield Ca, will accept patients from your facility in the event of an emergency. In the event you would require evacuation we would accept convalescent patients, not in an acut~ episode, of any type of illness, for admission to each an~ every empty bed available. In the event of extreme emergency we would provide space in our living, room, dining room and lobby to hold patients temporarily until more adequate 'accomodations could be arranged. SinCerely, . .. · Olive Harean. Administrator oM/tt / ...~ '%': · ~ ·; -(~ ~.... ,.'.~,':: Jerome L. Sturz BeVerly Manor 3601 San Dimas Bakersfield,CA 93301 Dear Mr. Sturz-. July 8, 1980 **'*.~':~.:j ...... This letter is to 'verify that Beverly Manor ~i~.~. ~:...' . Convalescent Hospital locate ?~.:~:!.~........***::... d at 2715 Fresno St .~.i~C....?.:.?./.,~..,,:i~. esno, CA.,will accept patients from your faci ty *~ ~*:!~** .., ..-:..~ '~ . . ~ * *~.**i~?*f'!,*':.i.~:~.i .... ~- cae event o ~j~,~-*'.,*~?*~:i~ ~%1:.:*; . f an emergency. ~,~Q~.~h.-.._..i~;,.*.-~.. = uvent you would require evacuation we wo ~:,}i~!*.~;~& ,.--...~-*~. =ccept convalescent ' atients ~:,~.,~,..~ ~,... .... ..~ ...... cute e lsod ~/.~*~.~.,/:~..~0~ any type of illness*, for admission ~,~..~,~ ....... ~ ~.. to each and eve~ tG.~t~:~.;:~ ::,:..~ y bed avazlable. In ~e e~-~ ~ ~ ~.~-t ~.~ ~-. :7; .'. . .:~;~.~d<~.,;~L ~ :~.. ~e ~ · . . . ~..~;..~:; ...,. ould p:ovzde space zn ou: lzvzng :oom, .... ~,.,~.... :oom and lobby to hold patients temporarily until ~ ..:-: ~; '~ .. ~'.:~?~-'~"t'.;:;-. mo:e adeguate accomodations cauld be .. :.-~ ~ ~.~ . . ~-~.~.f;.~.& :.- . ~ :"'~: "~': ~' Sincerely , .... "., .,..:,hU ,..,,/./, , '...~ ' ' ~ -.2' ' .'. .~.- Larry Cha$son' / *" · ~;",~ L. ... ~...7-.'- BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 (805) 326-39'79 JUh 12 1.q87 A.'d ............ BUSINESS NAME OFFICIAL USE ONLY ID# HAZARDOUS MATERIALS BUSINESS PLAN AS A WHOLE FORM 2A INSTRUCTIONS: 1. To avoid further action, return this form by 2. TYPE/PRINT ANSWERS IN ENGLISH. 8. Answer the questions below for the business as a whole. 4. Be as brief and concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA A. BUSINESS NAME: .. nOCATZO~ / ST~T APD.~SS: SECTION 2: EMERGENCY NOTIFICATIONS In case of an emergency involving the release or threatened release of a hazardous material, call 911 and 1-800-852-7550 or 1-916-427-4341. This will notify your local fire department and the State Office of Emergency Services as required by law. EMPLOYEES TO NOTIFY IN CASE OF EMERGENCY: NAME AND TITLE DURING BUS. HRS. AFTER BUS. HRS. SECTION 3: LOCATION OF UTILITY SHUT-OFFS FOR BUSINESS AS A WI{OLE A. NAT. GAS/PROPANE: Nodda~,~c%t- o~rr~c o,C kx~',l~n~ Gu%side. (nnal%~.z~_ '~c~ bk~c~cac, d ~C~loco ~.f~ B. ELECTRICAL: "~z'.0_~ ~oc+h- rn-,c~a~¢~ c~C- b~, U~,.T,~.~ i~d~ (.~c,a~ited elec~co.x ~ cn .a.ooc') C. WATER: Podo~. ~o~-~ r~tck'~?_~ oA ~30'~\~(~ 's~'~'- (r~e'~rY-~-~ ~xi\ef roocr~ Gq doo~ O. SPECIAL: -o E. LOCK BOX:E~__~/ NO IF YES, DOES IT CONTAIN SITE PLANS? FLOOR PLANS? IF YES, LOCATION: ~(kfirb Fro~Jr ~+r&~c~ Chk~ove. ~o~rW dooc YES / NO MS,SS? YES / NO (~D/ No ~(EVS? ~ NO - 2A - SECTION 4: PRIVATE RESPONSE TEA~ FOR BUSINESS AS A ~HOLE f~\ ernploHec$ ~cre_ ~q~e~rc~ccc~ o~ p~pe~ pr~~ ~' SECTION 5: LOCAL EMERGENCY MEDICAL ASSIST~CE FOR YO~ BUSINESS AS A ~HOLE SECTION 6: EMPLOYEE TRAINING EMPLOYERS ARE REQUIRED TO HAVE A PROGRAM WHICH PROVIDES EMPLOYEES WITH INITIAL AND REFRESHER TRAINING IN THE FOLLOWING AREAS. CIRCLE YES OR NO INITIAL A. METHODS FOR SAFE HANDLING OF HAZARDOUS MATERIALS:...' .................................... ~ES~ NO B. PROCEDURES FOR COORDINATING ACTIVITIES WITH RESPONSE AGENCIES: .......................... (YES~ NO C. PROPER USE OF SAFETY EQUIPMENT: .............. .~'/~~YES NO D. EMERGENCY EVACUATION PROCEDURES: ................. E~S~N0 E. DO YOU MAINTAIN EMPLOYEE TRAINING RECORDS: ....... YE~ NO REFRESHER NO SECTION ?: HAZARDOUS ~4ATERIAL CIRCLE YES OR NO DOES YOUR BUSINESS HANDLE HAZARDOUS MATERIAL IN QUANTITIES LESS THAN 500 POUNDS OF A SOLID, 55 GALLONS OF A LIQUID, OR 200 CUBIC FEET OF A COMPRESSED GAS: ...... YES NO I, H~k~'~/~l%C~ ~. ~-(Dt~3\~_.~ , certify that the above information is accurate. I understand that this information will be used to fulfill my firm's obligations under the new California Health and Safety code on Hazardous Materials (Div. 20 Chapter 6.95 Sec. 25500 Et Al.) and that inaccurate information constitutes perjury. DATE BAKERSFIELD CITY FIRE DEPARTMENT 2130 "G" STREET BAKERSFIELD, CA 93301 BUSINESS NAME: OFFICIAL USE ONLY ID# BUSINESS pLAN SINGLE FACILITY UNIT FORM 3A', INSTRUCTIONS 1. TO avoid further action, this form must'be 'r'eturned by: 2. TYPE/PRINT YOUR ANSWERS IN ENGLISH. 3. Answer the questions below for THE FACILITY UNIT LISTED BELOW 4. Be as BRIEF and CONCISE as possible. SECTION 1: MITIGATION, PREVENTION~ ABATEMENT PROCEDURES O,x'¥~en Tanlts o_~weol ir~ ~-Loc~ e_Z~sek. ~do ~o~,~5 o~/~ SECTION 2: NOTIFICATION AND EVACUATION PROCEDURES AT THIS b~IT' ONLY' - 3A - SECTION $: HAZARDOUS MATERIALS FOR THIS b~IT ONLY A. Does this Facility Unit contain Hazardous Materials? ...... ~ NO v If YES, see B. If NO, continue with SECTION 4. B. Are any of the hazardous materials a bona fide Trade Secret YES~ If No, complete a separate hazardous materials inventory form marked: NON-TRADE SECRETS ONLY (white form #4A-l) If Yes, complete a hazardous materials inventory form marked: TRADE SECRETS ONLY (yellow form ~4A-2) in addition to the non-trade secret form. List only the trade secrets on form 4A-2. SECTION 4: PRIVATE FIRE PROTECTION SECTION 5: LOCATION OF WATER SUPPLY FOR USE BY EMERGENCY RESPONDER$ SECTION LOCATION OF UTILITY SHUT-OFFS AT THIS UNIT OMLY. A. NAT. GAS/PROPAN~'~ B. ELECTRICAL: WATER: E. LOCK BOX: YES / NO IF YES, LOCATION: IF YES, SITE PLANS? FLOOR PLANS2 YES / NO MSDSs? YES / NO KEYS? YES / NO YES / NO IoD. # Page'_~__of ,-,/A UNIT #: /~'//4 BAKERSFIELD CITY FIRE DEPARTMENT FORM 4A-1 NON--TRADE SECRETS HAZARDOUS I~IATE R I ALS INVENTORY BUSINESS NAME: '~,T~_..,j.~ ~'~3'~' C. Or%~~OS~W~NIR NAME: ~~ ~f~'~ FACILITY ADDRESS: ~[ 5A~ ~(~a$ ADDRESS: ~ ~~,VO~ a~FACILITY UNIT NA~E: CITY, ZIP: ~cS~ ~ ~% ClTY,ZIP.:~d~, C~ ~11~-- / ' I ONLY 1 2 3 4 5 6 7 8 9' 1~" TYPE MAX ANNUAL CONT USE LOCATION IN THIS % BY HAZARD D.O.T CODE AMOUNT AMOUNT UNIT CODE !CODE FACILITY UNIT WT. CHEMIqAL OR COMMON NAME CODE GUIDE NAMe: EMERGENCY CONTACT: ~d~f(~d~ ~-O%,,3t9-~ ., ~RGENCY cONTACT: ~"~xCyq. O~3.~,"~ ., NCIPAL BUSINESS ACTIVITY: TITLE:.~m~hl~W'r*'~ SIGNATURE: TITLE: ~dm~'v~,iah~o._~"- PHONE # BUS HOURS: AFTER BUS HRS: .OU S: ~9fS~ ~0~''' AFTER BUS "RS: - 4A-1 - O. .Eyacuation of the Hospital: The follo.~lng persons shall have the authority° to order the evacuation of patients from the hospital, in the order that they appear below: a. Administrator b. Charge Nurse/Director of Nursing c. Fire Marsh~]l " d. Chief Medical Officer . 2. If the patients are to be evacuated, use beds, wheelchairs, blanket drag or approved carry method.. Take patient's outside~throu~h the nearest exit, and out on t~.-the facility's paved parking lot, and be sure to cover the patient ~th a blanket. Charge nurse will '~ assign staff members to care for the patients once they ha~e been evacuated, ~nd to quite their fears. Do~ not leave the evacuated patients unattended. '~ 3. In the event of a total evacuation, the administrator or the' Director of Nurses shall notify other medical facilities Within the area that we are evacuating our patients and' that the'.patients w~11 be directed to the~. Such medical facilities to be c=]3ed will include Memorial Hospitkl, and San Joaquin Hospital; other nursing homes, such as Bakersfield Convalescent Hospital, F~lltop and · .: Colonial Convalescent Hospitals. If necessary the local schools may ".- be contacted to prepare for the receiving of e~acuated patients,' "."to send ~11 available ~r. ansportatton~ This decision to 'call'these · . places for transportation sh~l] depend on the situation ~t the ~ · '.. time., au.d should be coordinated as ~uch as POssible. The!'a~m~uistrat¢ ~ and/or Director of Nursing shall make sure that transferred 'patient' s medical records are kept up to date ~th such information as time of transfer, new location, by whose orders was the transfer' done, by what means was the transfe~ accomplished, and if possible, was the patient's family notified of such a move. -,. ALI medical records Shall be safeguarded at all times, 'and if it should become necessary, for safety purposes, the ~.' administrator or responsible party designated by him, shal~..' order the transfer of all medical records to: Beverly Enterprises '.'i~ ' F, VJ, South-~,,~'~.1<'5 ... "" ~'.' " Pasadena, CA 91101 ..~. (213) 577-~J~111 ~..;. . · DISASTER PLAN ( cont ' d) (22) C. Evacuation of our Hospital: (con't) In the event of a major external disaster, many decisions may be made by our local authorities. It shall be the duty of the administrator or responsible party (Director of Nursing/Charge Nurse) to coordinate any instructions which we may receive from these local authorities within the framework of this disaster plan, to always insure the continued care and safety of our patients, and of our staff. In the case of blind and hard of hearing patients first priority must be given in an evacuation because they will not be aware of the alarm. The charge nurse will be responsible for directing their evacuation. EMERGENCY TELEPHONE LIST, FIRE AND DISASTER LIST EMERGENCY NUMBERS FIRE DEPT. 324-4542 POLICE DEPT. 327-7111 WATER DEPT. 324-6011 P G & E 327-4611 TELEPHONE 327-6011 SEWAGE 325-1309 PLUMBER 327-8668 ELECTRICIAN 399-5154 AIR COND. 323-2818 or 911 DRUG SUPPLIES MEDICAL PHARMACY 327-3956 GREGG's PHARMACY 327-9749 RENTAL'EouIPMENT MEDICAL PHARMACY 327-7524 HOPPER MEDICAL 861-7018 HEALTH MART-EMERGENCY EQUIPMENT PROBLEM 327-1492 FOOD SUPPLY SMART AND FINAL LIBERTY FOODS 327-7223 1-800-742-1661, LABORATORY BAKERSFIELD CLINICAL LAB 327-9641 RADIOLOGY PORTABLE x-ray 325-8410 PHARMACIST CLARK GUSTAFSON 327-~524 CHURCHES CATHOLIC '323a5009 BAPTIST ~325~1978 LUTHERAN ''323-3355 METHODIST 832-8778 PRESBYTERIAN 325-9419 KEY PERSONNEL: Person on duty will be responsible until relieved ADMINISTRATOR --MARILYN SHAPAZIAN 871-5502 or 871-8046 OFFICE MANAGER --KATHY SCERRA 831-8942 DIRECTOR OF NURSES--CAROL MULHALL 871-7644 ASST DIRECTOR--DEANA MONTGOMERY 746-4166 b~INTENANCE -- JIM CLAUNCH 366-0578 DIETARY -- LEE ANN GRAVES 833-2764 POLICE DEPT. 327-7111 or 911 SHERIFF DEPT.327-3392 CIVIL DEFENSE 871-7301 HOSPITALS MEMORIAL 327-1792 MERCY 327-3371 SAN JOAQUIN 327-1711 KMC 326-2000 BKSFD COMM HOSP 399-4461 MORTUARIES MISH 399-9391 PAYNE AND SONS''324-9431 GREEN-LAWN ''324-9701 HILLCREST ''366-5766 ~'OXYGEN HEALTH MART ''327-1492 'BLOOD RED CROSS ''324~6427 'AMBULANCE'SERVICE HALL 327-4111 GOLDEN EMPIRE 327-9000 iCOMMITTEE'PHYSCIANS DR. MATYCHOWIAK'325~4850 DR. AP, DELL '~'871-1836 or 822-4402 'MEDICAL ~DIRECTOR DR. ARDELL ~1~1836~ or 822-4402 IF UNABLE. TO CONTACT ATTENDING PHYSCIAN -- PLEASE CONTACT MEDICAL DIRECTOR TYPES OF'DISASTERS: 1.INTERNAL 2.EXTERNAL 3.DISASTER THREATS DURING INTERNAL DISASTER PATIENTS ~Y BE EVACUATED TO MEMORIAL HOSPITAL EMERGENCY NUP~ERS Ad~inistrator-~ Marilyn Shapazian Director of Nursing- Carol Mulhull Emergency Maintenance- Jim Claunch EMERGENCY PHYSICIAI~S 871-5502 871-7644 366-0578 1. David Ardell, M,D, 2, Francis MatychoNiak, M,D, HOSPITALS 1 MEmorial Hospital 21 Mercy Hospital 3, San Joaquin Hospital 4, Bakersfield CaTmunity Hospital 5, Kern Medical Hospital 399-9111 22_q China Grade Loop, Oildale 325-4850 190]. Truxtun, Bakersfield 327-1792 32_7-3571 327-1711 399-4a61 323-7651 1, Halls 2, Golden Empire AMBULANCES 327-4111 32?-9000 SERVICES 1, Fire I)epartment 2, Police Depar~ent 324-45a2 327-7111 SERVICES TO BUILDING 1, Pacific Gas & Electric 327-46].1 1918 h. st, Bakersfield 2, Southern Calif, Gas Co, 399-2911 15].0 n, chester Bakersfield 3. Pacific Telephone Co. 327-6011 2120 L. st. BakerSfield 4. Calif, Water Service 324-6011 1920 eye st, Bakersfield OTHER EMERGENCY NUMBERS 1. Department of Health 86].-2231 1700 Flower St, Bakersfield 2, ~erican Red Cross 324-6427 239 18th, Bakersfield PHARMACY 1, M~ical Pharmacy 327-7524 1907 17th, Bakersfield 1, Health Mart OXYGEN 327-1492 2700 "H" st, Bakersfield Beverly Manor Convalescent Hospital 36CLl San Dimas Bakersfieldj. Ca, 93301 ~ERGENCY I~dMBERS Administrator::Marilyn Shapazian 871-5502 Director of Nursing 871-7644 Carol Mulhul! Dietary Supervisor 392-1486 LeeAnn Graves Maintenance Supervisor 366-~578 Jim Claunch E~-£RGENCY PHYSIC IANS 1, 'David Ardellj M,D, 2, Francis Matychowiak~ M,Dp 399-9Clll 325-4850 1, Medical Pharmacy PHARMACY 327~7524 AMBULANCE 1, Halls 327-4111 2, Golden Empire 327-9000 POLICE DEPARI~ENT: 327-7] 11 FIRE DEPARTMENT: 324-454.2 CHURCHES: 1, Catholic- 323-5009 2, Baptist- 325~ 3, Luthern--'323-3355 4. Methodist- 832-8778 5, Presbyterian' ' 325-9419 TYPES OF DISASTER: 1, Intemal Disaster 2, Extemal Disaster 3, Disaster Threats UNUSUAL OCCURENCES Occurences such as epidanic outbreaks, poisoning, fires,' major accidents~ deaths from unnatural causes, or other catastrophies and..unusual occurences which threaten the welfare, safety or health of patients, personnel or visitors, shall be reported inTnediately tp .the Administrator, or in her absence, the Director of Nursing Services. An incident report will be filled out ccmpletely by the person reporting such occurences. This report shall be kept by the Asministrator on file for at least one year. If the Administrator does not feel that the reported incident does fall into the areas listed above, the local Health Officer and local representative of the Public Health Department shall be notified within 24 hours of such an incident by either telephone, and confirmed in writing, or by telegraph. While many things may be considered an Unusual Occurences the Acininistrator should be contacted when ever there is an unusual occurence. Sa~e specifics are: If the fire deparl~ent or police department need to be called, contact the Administrator as soon as possible. 871'5502 If a patient (wanders fr'cm the facility) cannot be found, check the building and inTnediate area. If patient cannot be located call local police inTnediately and contact the Acininistrator. 871-5502 Any maintenance or repair anergency - contact Jim Claunch Maintenance Supervisor -366-0578 If you cannot reach him j contact the Administrator - 871-5502 Any specific nursing problan, call the Director of Nursing Servicesj Carol Mulhull - 871-7644 ~ , All other a~ergency nLrnbers including anergency physicians are posted by each telephone: