AHCA Consumer Friendly Plan - Palm Beach County Home



CONSUMER-FRIENDLY SUMMARYOF THE EMERGENCY ENVIRONMENTAL CONTROL PLANFacility InformationFacility Name: FORMTEXT ?????Facility Type: FORMCHECKBOX Nursing Home FORMCHECKBOX Assisted Living Facility License # FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????Zip: FORMTEXT ?????Administrator Name: FORMTEXT ?????Contact Number(s): FORMTEXT ?????This Facility Is: FORMCHECKBOX Located on a campus with other facilities under common ownership FORMCHECKBOX Located in a multistory building FORMCHECKBOX A stand-alone single story buildingAlternate Power SourceOnsite Alternate Power Source: FORMCHECKBOX Portable generator FORMCHECKBOX Fixed generator FORMCHECKBOX Other: FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Size: FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Size: FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Size: FORMTEXT ?????The alternate power source is capable of powering the following equipment: FORMCHECKBOX Entire Facility FORMCHECKBOX Lights FORMCHECKBOX Refrigeration FORMCHECKBOX Life Safety Systems FORMCHECKBOX Air Conditioning FORMCHECKBOX Heating Systems FORMCHECKBOX Other: FORMTEXT ?????Implementation of the alternate power source will be complete on FORMTEXT ????? (Date)Cooling MethodThe following kind(s) of equipment will be used to cool the facility: FORMCHECKBOX Air Conditioner(s) FORMCHECKBOX Spot Cooler(s) FORMCHECKBOX Chiller FORMCHECKBOX Fan(s) FORMCHECKBOX Other: FORMTEXT ?????Temperature Controlled Area(s)The area(s) the facility plans to keep at 81 degrees or below using the emergency power source is: FORMCHECKBOX Within the licensed facility FORMCHECKBOX In another location on the campusThe following area(s) will be cooled. FORMCHECKBOX Entire Facility FORMCHECKBOX Living Room FORMCHECKBOX Dining Room FORMCHECKBOX Resident Room(s) FORMCHECKBOX Common Area(s) FORMCHECKBOX Hallways FORMCHECKBOX Other Area(s): FORMTEXT ?????The net square footage of the area to be cooled is FORMTEXT ????? square feet.How many people are planned to use this area? FORMTEXT ?????Will there be beds available in the cooled area? Yes FORMCHECKBOX No FORMCHECKBOX ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download