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Body Art Inspection Report Date(MM/DD/YY) D q�11 County of San Joaquin County,Environmental Health Department 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number (209)468-3420 www.sioov.orolehd ITA 4D Permit Type FO Facility Name Address city Zip Code CT Semk S4xt X116 Tat �, l 5�. �Ct��>n 1 s3� S„ �c�Gtti 1A d� Permit/Registration Holder Name Permit p.Date Total Time Inspection Type RISK FACTORS AND INTERVENTIONS Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. In=In Compliance Out=Not in Compliance N/0=Not Observed N/A=Not Applicable COS=Corrected On Site fl & �l•. ,:�TATT00ANDPE116"t COS E "CHINE '"`CLEA IN `ANU STERILIZA710N 36�a SAFETY AND SA IIT, 0 k�o[fr cosaa 1 0 1. Autoclave is approved and effective-passed In NiO 18. Safe machine design 11 13 0 0 N/ inte rator test N/ /0 2. Process of cleaning,labeling,packaging and 0 El In / 19. Machines cleaned and disinfected between El 0 N/A sterlizling items correctly N/ clients In 0 3. Autoclave loaded correctly/packages allowed to In N/ 20. Parts replaced between clients-grommets, 0 El N/A dry N/ elastic bands,etc. In_W0 4. Integrators used/monthly spore test/log 0 0 OWNMOS11:0 TAMINATION maintainedA .. In 0 5. Decontamination/sanitation area separate and 13 11 1 nk,NIJO 21. Workstation/procedure area decontaminated N/ supplied* NIA 15-100 6. Invoices and log kept for disposable,pre- I NIO 22. Chemical disinfectant use N/A sterilized equipment,backupsupplies available* Al" 11 Chemical used: f i'/1 6 344`Ct'!�? In N10 7. Sharps containers supplied,labeled,used and In W1 23. Disinfectant used sufficient contact time Wet N/A disposed of correctly N/A contact timeprovided: In N/0 8. Jewelry,tattoo and piercing equipment-storage0 I N/O 24. Barriers available and used as part of N/A and use NIA procedure 111 In N/0 25. Products applied to skin are single 6 RA( 0 E e E . .. 4 . :; N/A use/dispensed ensed ase tical) In N/0 9. No eating,drinking or smoking-clean clothes In N10 26. Storage of inks,pigments,needles,tubes,etc,, N/A /A 1 /0 10. Hands washed effectively and timely I N/0 27. Jewelry,Inks,Needles etc approved and used 0 11 NIA In WO 11. Handwashing facilities properly supplied and f In I 28. Cross-contamination avoided during all phases 0 E N/A accessible,warm table water* `� N/A of procedure h /0 12. Personal protective equipment available and 1 BES, BU1S NESSR ICE �..' b { /A used,eyewash station available jN/O 29. Areas separated/no living or sleeping13 0 NIAquarters/no animals' I 13. Branding is completed with no other customers in ❑ 13 In N/0 30. Floors and walls clean and in good repair, ❑ 11 N/A procedure area /A adequate light 1 N/O 14. Customers eighteen(18)years of age or older JU N10 31. Workstation,surfaces,including chairs,,etc.in N/A 0 13 N/A good repair;trash removed frequently In N/0 15. Skin prepared for procedure. 0 El In N10 32. Permit/registration and required signs posted N/A N/A In N/0 16. Client records available-Consent form& El In N10 33. IPCP and employee training records and N/A questionnaire N/A Hepatitis B vaccination status present In N/0 17. Aftercare instructions given to client In N/0 34 Restrooms available,stocked 0 11 N/A N/A 1LAReceived b Print: '� Received b (Si nature: hone: -Zoo( q-79 I-7 1 - S ecialist(Print): YY'1I VS Specialist(Signature): A A.X Phone This report is an Official Notice of Violation.Corrections must be completed in the time specified. reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page_of