Use this SOP to protect employees, patients, and visitors from injury during a fire, earthquake, or other non-medical emergency; prevent fire hazards; evacuate safely; account for everyone; and document training and inspections.

📚 Resources Needed

The clinic's current floor plan and an onsite walk-through with someone familiar with the building's life-safety systems
Current building or vendor records for alarms, smoke detection, sprinklers, emergency lighting, and portable extinguishers
Staff schedule and patient or visitor information used for accountability
A printed or accessible copy of the adopted evacuation map, monthly inspection log, training acknowledgment, and incident-report process

✅ Before You Start

Complete onsite verification before adopting or training from this plan.
Verify the exact street address and suite that staff will give to 911.
Verify the building alarm method, any backup method, the evacuation meeting point at the corner of Broadway and 4th Street at the street sign, primary and alternate routes, and fire-equipment locations.
Assign primary and alternate job titles for incident lead, 911 caller, sweeps, accessibility assistance, accountability, and firefighter liaison.
Choose and document whether the clinic is evacuation-only or allows designated trained staff to use extinguishers.
Do not present unverified site details as final facts. Update the evacuation map only after an onsite review.

🚀 Tips & Tricks

The nearest safe verified exit is the correct route; do not make people cross the clinic to reach a preferred door.
Anyone should call 911 from safety if the assigned caller is unavailable.
No one delays evacuation for belongings, medications, records, equipment, a sweep, or property protection.
PASS applies only to an authorized and trained person who still has a safe exit behind them.

📘 Instructions

Step 1: Verify And Adopt The Site-Specific Plan

Confirm the exact clinic boundary, street address, suite, alarm and backup methods, the evacuation meeting point at the corner of Broadway and 4th Street at the street sign, primary and alternate routes, and fire-equipment locations onsite. Staff must know where the fire exits and stairs are located.
Confirm the division of responsibility between the clinic, property manager, building, and vendors for alarms, sprinklers, common-area exits, exit signs, emergency lighting, inspections, and service records.
Assign primary and alternate staff roles. Approve and date the completed plan and evacuation map before staff training.

Step 2: Prevent Fire Hazards Every Day

Keep exit doors, aisles, hallways, fire doors, and routes to the exterior unobstructed and accessible whenever the clinic is occupied.
Do not cover exit signs, evacuation diagrams, alarms, extinguishers, or fire-equipment identification.
Prohibit smoking, candles, matches, and unauthorized open flames inside the clinic and in other posted or prohibited areas.
Remove damaged cords, warm or sparking equipment, and questionable electrical devices from service. Do not daisy-chain power strips or run cords across walking paths.
Keep coffee and break-area appliances on stable, noncombustible surfaces away from paper and other combustibles. Power them down when appropriate.
Store sanitizer, disinfectants, and other flammables in labeled or original containers away from heat and ignition. Follow the safety data sheet and manufacturer instructions.
Remove paper, cardboard, rubbish, and flammable waste routinely. Place flammable rubbish in a closed metal container, keep flammable waste rags and materials away from possible fire sources, and dispose of oily or greasy rags properly. Never store combustibles in exits, corridors, electrical areas, or against heat sources. Never wedge a fire door open for ventilation.
Secure oxygen cylinders or medical gas against tipping, protect valves, and keep them away from heat, flame, smoking, oil, and grease.
Maintain at least 10 inches of clearance below and around sprinkler heads, plus any greater clearance required by the building or fire authority.

Step 3: Respond To Fire, Smoke, Or A Burning Odor

Warn everyone nearby and sound the alarm using the verified pull alarm station or telephone. If using a telephone, give the location and extent of the fire. Do not investigate alone or assume an alarm is false.
Call 911 from a safe location. Give the exact verified address and suite, describe the condition and its location, and state whether anyone needs help.
Before opening a door, feel it for heat with the back of your hand, starting at the top. If the door is hot, do not open it. If the door is cool, open it slowly and be prepared to close it quickly. Begin evacuation using the nearest safe verified route. Walk quickly but in an orderly manner; do not run. Use the alternate route if heat, smoke, or fire blocks the first route.
Immediately evacuate employees, patients, and visitors who are in immediate danger. Assist patients and visitors with clear directions and assigned mobility, sensory, cognitive, language, or other support.
If there is time and no immediate danger, close windows and doors in the area. Close doors behind the group only when feasible and safe. Do not lock doors or delay evacuation to move property.
Do not use elevators. Use the verified stairs or level exit route and follow firefighter directions.
Report to the evacuation meeting point at the corner of Broadway and 4th Street at the street sign. Account for staff, patients, and visitors, and give missing or last-known locations to firefighters. No one may reenter or return to retrieve personal items. Above all, remain calm.

Step 4: Apply The Adopted Extinguisher Rule

Evacuation-only: all staff evacuate. No employee is expected or authorized to fight a fire.
Designated trained users: only named staff with required education and training may attempt to extinguish an incipient-stage fire after the alarm and 911 are activated and while a safe exit remains continuously available. Everyone else must leave the area. Improper extinguisher use can result in injury.
An authorized user keeps a clear exit behind them and uses PASS: Pull the pin, Aim at the base, Squeeze the handle, and Sweep side to side.
Stop immediately and evacuate if the extinguisher empties, the fire spreads, smoke or heat increases, or the exit becomes threatened.
After any discharge, keep the area closed, report it to firefighters, document the incident, and replace or service the extinguisher before returning it to service.

Step 5: Evacuate, Assist, And Account For People

Assigned sweepers check only areas that can be checked quickly and safely. They never enter smoke, delay their own evacuation, or lock doors.
The accountability lead uses the staff schedule and available patient and visitor information when safe and practical.
Identify reasonable evacuation assistance at check-in or when a need becomes apparent without delaying care or labeling the person publicly.
Mobility devices should accompany the person when possible. Staff must not lift or transfer beyond their training and capability.

• If a person cannot use stairs, follow the building's verified emergency procedure and immediately give the person's location to 911 and firefighters. Do not improvise an unapproved refuge location.

Service animals evacuate with their handlers whenever possible.

Step 6: Follow Earthquake Safety Procedures

Move away from windows and glass.
During the earthquake, take cover under a sturdy desk or table.
If you are in a corridor, sit down and protect your head.
As a last resort, brace yourself in a doorway.
If you are in an elevator, sit down and wait until the elevator stops and the doors open; then get out of the elevator and seek shelter in the corridor.
After the earthquake, assess damage and check everyone nearby for injury.
Provide first aid only if qualified.

Step 7: Inspect, Maintain, And Keep Records

Check portable extinguishers visually each month. Keep them accessible, identified, charged, and operable, and arrange annual professional maintenance.
Confirm the visible condition and building or vendor testing schedule for alarms, smoke detection, sprinklers, and emergency lighting. Report impairments immediately.
Check exits, aisles, doors, signs, and maps routinely and during the monthly inspection. Correct obstructions immediately.
Document every failed check and corrective action. Correct or isolate any immediate life-safety risk promptly.
If safe occupancy is uncertain, contact the building and the appropriate emergency or fire authority and do not continue normal operations in an unsafe condition.

Step 8: Train Staff And Review The Plan

Review the adopted plan with each employee when it is first issued, when the employee is initially assigned, when responsibilities change, and whenever the plan changes.
Training covers the alarm, both routes, the evacuation meeting point at the corner of Broadway and 4th Street at the street sign, accountability, assigned roles, patient assistance, earthquake response, no-elevator and no-reentry rules, hazards, and the adopted extinguisher rule.
When extinguisher use is authorized, document required education and designated-user training initially and at least annually.
Review the plan after a fire or alarm event, drill, construction or layout change, staffing change, building-system change, identified deficiency, and at the scheduled review date.
Retain signed FSR-readiness training evidence for at least three years unless another applicable rule or contract requires longer retention.

Step 9: Complete Follow-Up After A Fire Or Alarm Event

Wait until emergency services release the site before beginning recovery.
Document the event, notifications, injuries or exposures, equipment used, operational impact, and immediate corrective actions.
Preserve relevant alarm, inspection, service, training, and incident records.
Notify insurers, regulators, property management, and health-plan contacts when required.
Conduct a debrief focused on system improvement and update the plan, map, supplies, roles, or training before resuming any process found deficient.

🛠 Troubleshooting

The Alarm Method Or Evacuation Meeting Point Cannot Be Used

Use the verified backup alarm method when the primary alarm cannot be activated. If the evacuation meeting point at the corner of Broadway and 4th Street at the street sign cannot be reached safely, move to the nearest safe exterior location and immediately tell 911 and responding firefighters where the group is located.

A Primary Route Is Blocked

Use the nearest safe verified alternate route. Do not move toward heat, flame, or smoke. Correct or isolate the obstruction and document the corrective action before normal occupancy continues.

A Person Cannot Use The Stairs

Follow the building's verified emergency procedure, keep the person informed, and immediately give the person's exact location to 911 and responding firefighters. Do not improvise an unapproved refuge location or attempt a lift beyond training.

An Extinguisher Is Missing, Discharged, Or Shows A Problem

Keep the area protected, report the condition, arrange immediate replacement or professional service, and document the issue. Do not return a discharged or questionable extinguisher to service.

Someone Is Missing At The Evacuation Meeting Point

Give firefighters the person's name and last-known location. Staff must not reenter to search.

✅ Completion Check

The exact address, suite, alarm method, backup method, evacuation meeting point at the corner of Broadway and 4th Street at the street sign, and two evacuation routes were verified onsite.
Fire-equipment locations and building responsibilities were confirmed.
Primary and alternate staff roles and the clinic's extinguisher-use rule were approved.
The evacuation map is complete, dated, approved, and posted where required.
Exits and fire equipment are clear and usable, and immediate hazards were corrected or isolated.
Staff completed training and signed the acknowledgment.
Monthly inspection, annual service, training, and corrective-action evidence is stored where it can be retrieved. Fire and earthquake procedures, injury checks, and qualified first-aid response were reviewed with staff.

References

OSHA 29 CFR 1910.38 — Emergency Action Plans

OSHA 29 CFR 1910.39 — Fire Prevention Plans

OSHA 29 CFR 1910.157 — Portable Fire Extinguishers

California Department of Industrial Relations, Title 8 §3221 — Fire Prevention Plan

CalOptima Health Facility Site And Medical Record Review Audit Packet: Fire Safety And Emergency Non-Medical Procedures, page 57

Source Protocol Revision: Apr 28, 2026

This internal readiness SOP supports CalOptima and DHCS Facility Site Review access and safety requirements. It does not replace the full standards or a determination by CalOptima, DHCS, OSHA, the building official, or the fire authority.

Fire Safety And Emergency Non-Medical Procedures