Use this SOP to maintain a safe, accessible clinic environment; help patients who need accessible parking or arrival assistance; keep exits and patient areas usable; alert team members during an emergency; and retain evidence for CalOptima and DHCS Facility Site Review readiness.

📚 Resources Needed

  • The clinic's current floor plan, posted evacuation routes, and an onsite walk-through of patient areas, exits, and life-safety systems

  • The current accessible-parking instructions, the appointment-scheduling accessibility checkbox, and the arrival-assistance phone number

  • Current inspection or service records for fire extinguishers, alarms, smoke detection, sprinklers, fire doors, and exit lighting that apply to the site

  • The access-and-safety inspection log, corrective-action record, and staff training acknowledgment

✅ Before You Start

  • Walk the patient route from the designated accessible parking space to the primary entrance, waiting area, restroom, and exam area.

  • Confirm the scheduling checkbox works, the parking instructions are accurate, and the published arrival-assistance phone number reaches a team member during appointment hours.

  • Verify exits, doors, aisles, signs, lighting, evacuation maps, wheelchair clearances, fire equipment, and emergency safeguards onsite.

  • Confirm the site has 10 or fewer employees and that a direct voice alert can be heard by every employee in every normally occupied area.

🚀 Tips & Tricks

  • Treat the scheduling checkbox as an action request. The patient should receive parking and arrival instructions without having to repeat the need.

  • Test the arrival-assistance number from outside the building so staff know what the patient experiences.

  • Check exit paths after deliveries, room changes, or temporary work; short-term storage can create the same hazard as permanent storage.

  • Use a tape measure when confirming wheelchair clearances instead of estimating.

  • Keep access, inspection, training, and corrective-action evidence together so it can be retrieved during a site review.

📘 Instructions

Step 1: Provide Accessible Parking And Arrival Assistance

  • Maintain a designated accessible parking space in close proximity to the accessible primary entrance. A patient who needs accessible parking or arrival assistance checks the designated box when scheduling an appointment.

  • The scheduling process gives the patient clear information about where to park and the phone number to call upon arrival.

  • When the patient calls, a team member responds promptly, confirms the patient's location, meets the patient when requested, and provides reasonable assistance into the clinic.

  • If the designated accessible space is unavailable, staff explains the closest safe alternative and provides the assistance needed for access.

Step 2: Maintain Accessible Entrances And Exits

  • Keep the primary entrance and all exterior and interior exit doors usable by people with disabilities, regardless of occupant load.

  • Keep doorways, landings, ramps, and the route from parking to the clinic clear of furniture, deliveries, equipment, cords, and other barriers.

  • If a barrier prevents normal access, notify the Office Manager immediately and provide a safe, reasonable alternative for the patient to receive services.

Step 3: Maintain Wheelchair Clear Space

  • Maintain at least 30 inches by 48 inches of clear floor space for a stationary adult wheelchair and occupant in waiting and exam areas.

  • Maintain a clear turning area of at least 60 inches in diameter or a 60-inch square where wheelchair turning space is required.

  • Keep required clear spaces free of movable chairs, trash containers, supply boxes, carts, and equipment.

  • Correct any obstruction immediately or keep the affected area out of use until safe access is restored.

Step 4: Keep Exit And Evacuation Routes Clear

  • Keep every exit route free and unobstructed at all times. Do not place materials or equipment in an exit route, even temporarily.

  • Keep each exit visible and marked with an Exit sign. Do not cover signs, doors, or evacuation maps.

  • Post clear, easy-to-follow evacuation routes in visible locations, including hallways, exam rooms, patient waiting areas, and at elevators, stairs, and exits.

  • Maintain at least 36 inches of clear passage along an accessible route. A doorway may narrow the passage to no less than 32 inches.

Step 5: Maintain Lighting And Emergency Safeguards

  • Maintain adequate lighting in corridors, walkways, waiting rooms, exam rooms, restrooms, and other patient-flow or work areas.

  • Keep sprinkler systems, alarm systems, smoke detection, fire doors, exit lighting, and other emergency safeguards in proper working order at all times.

  • Keep at least 10 inches of clearance between sprinkler heads and stored materials, or more when required by the building or fire authority.

  • Report a failed light, damaged door, blocked sprinkler, alarm problem, or other life-safety defect immediately and document the corrective action.

Step 6: Maintain Fire Safety Equipment

  • Maintain at least one of the following types of fire-safety equipment onsite: a securely mounted fire extinguisher that is fully charged and operable; smoke detectors with intact batteries; or an automatic sprinkler system in every room, including the restroom, with at least 10 inches of clearance between sprinkler heads and stored materials.

  • Keep fire extinguishers accessible, identified, charged, and operable. Visually inspect portable extinguishers monthly and arrange annual professional maintenance.

  • Retain the annual inspection or service record. A receipt may serve as evidence when a new extinguisher is purchased.

  • If required fire equipment is missing, discharged, damaged, or out of service, report it immediately and provide equivalent protection before the affected area continues normal use.

Step 7: Use Direct Voice Communication For The Employee Alarm

  • Besa Health maintains an operable direct voice communication procedure as its employee alarm method because the site has 10 or fewer employees.

  • A team member who identifies a fire or other emergency immediately gives a distinct, recognizable voice warning that states the type and location of the emergency loudly and clearly enough for every employee to hear.

  • Team members repeat the alert as needed, confirm nearby team members heard it, and begin the applicable emergency response or evacuation procedure.

  • A separate backup alarm system is not required while the site has 10 or fewer employees and every employee can hear the voice alert. If staffing, layout, noise, or operations prevent every employee from hearing it, leadership must establish an appropriate alarm method before relying on direct voice communication.

Step 8: Inspect Train And Review

  • The Office Manager or designee checks accessible routes, clearances, exits, signs, lighting, evacuation maps, fire equipment, emergency safeguards, and the arrival-assistance workflow on the adopted schedule.

  • Correct immediate hazards at once. Record deficiencies, interim controls, the person responsible, and the date correction was completed.

  • Train team members when assigned, review the voice-alert and accessibility-assistance procedures at least annually, and retrain whenever the process, facility, staffing, or assigned responsibilities change.

  • Review this SOP after an incident, complaint, failed inspection, facility change, scheduling change, or change to the arrival-assistance phone number.

🛠 Troubleshooting

The Accessibility Checkbox Is Missing Or Does Not Work

Provide the parking instructions and arrival-assistance number directly to the patient, record the accessibility request in the approved scheduling workflow, and report the defect for correction. Confirm the patient received the information before the appointment.

A Patient Arrives Without Requesting Assistance

Respond when the patient calls or when the need becomes apparent. Confirm the patient's location, provide reasonable assistance, and update the appointment record when appropriate so future visits are easier.

The Accessible Parking Space Is Unavailable

Give the patient the closest safe parking or drop-off option and send a team member to assist. Report the blocked or unavailable space to the Office Manager or property contact and document the corrective action.

An Exit Route Or Required Clear Space Is Blocked

Remove the obstruction immediately when safe. If it cannot be corrected at once, keep the affected area out of use, provide a safe alternate route, notify the Office Manager, and document the issue.

The Voice Alert Cannot Be Heard By Every Employee

Use any immediate available means to warn the team during the emergency. Afterward, stop relying on voice-only alerts until leadership establishes a method that reaches every employee and updates this SOP and staff training.

A Safety System Or Fire Extinguisher Fails A Check

Report the condition immediately, arrange repair or replacement, document interim protection, and do not continue normal use of an unsafe area or return questionable equipment to service.

✅ Completion Check

  • The accessible parking route and primary entrance were walked and verified.

  • The scheduling checkbox, parking instructions, and arrival-assistance number were tested.

  • Waiting and exam areas meet the required wheelchair clear-space and turning-space measurements.

  • Exits, aisles, doors, signs, evacuation maps, and accessible routes are clear and usable.

  • Lighting, emergency safeguards, and fire-safety equipment are working and required records are available.

  • The site has 10 or fewer employees and every employee can hear the direct voice alert.

  • Team members completed training on accessibility assistance, direct voice alerts, and their emergency responsibilities.

  • Identified deficiencies were corrected or controlled, documented, and assigned for follow-up.

References

OSHA 29 CFR 1910.37 — Maintenance Safeguards And Operational Features For Exit Routes

OSHA 29 CFR 1910.157 — Portable Fire Extinguishers

OSHA 29 CFR 1910.165 — Employee Alarm Systems

CalOptima Health FSR/MRR Audit Packet — Access And Safety Standards, page 25

Source Protocol Revision: May 11, 2026

Internal readiness SOP only; the full CalOptima, DHCS, OSHA, building, and fire-authority standards control.