111024230040_0001.pdfDA'M
AGING AND ADULT SERVICES ADMINISTRATION
A t�m FIRE SAFETY EVACUATION PLAN WAC 388-76-200(11)
An Adult Family Home shall have a posted plan for evacuation to safe areas in event of fire. Draw a diagram of the floor plan
of your home in the space proveded below. Indicate escape routes and designate where staff and residents should meet
outside the residence. Indicate the location of fire extinguisher(s) and smoke dejector(s).
INSTRUCTIONS: Provider/Reside on.
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EXI-74
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