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F <br /> ° °us• c Body Art Inspection Report Date(MM/DD/YY) �� L <br /> 2' y County of San Joaquin County,Environmental Health Department <br /> 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number <br /> (209)468-3420 www.sioov.oro/ehd L4+r1 <br /> Permit Type c� <br /> 4� FORM <br /> Facility Name Address City Zip Code CT -� <br /> Cjsb S. ll1. �l-Ly 0 SAn J 14 1 V1 <br /> Permit/Registration Holdej Name 1lI�_ Permit Exp.Date Total Time Inspection Type <br /> Lo <br /> WT atI)h I"E, �Owt'ne <br /> RISK FACTORS AND INTERVENTIONS <br /> Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. <br /> Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. <br /> In=In Compliance Out=Not in Compliance N/0=Not Observed N/A=Not Applicable COS=Corrected On Site <br /> t-"---T ffiN PC,L2041 "D <br /> f? t <br /> o <br /> In N/0 1. Autoclave is approved and effective-passed o In N/0 18. Safe machine design <br /> lA <br /> integrator test <br /> In 2. Process of cleaning,labeling,packaging and In kUO 19. Machines cleaned and disinfected between <br /> N/A sterliziin items correctlyclients <br /> I 0 3. Autoclave loaded correctly/packages allowed to In11 0 <br /> N/0 20. Parts replaced between clients-grommets, <br /> /A dry N/ elastic bands,etc. <br /> In 4. Integrators used/monthly spore test4og �►° _ I <br /> NIA maintained SIB <br /> In N/0 5. Decontamination/sanitabon area separate and 11 0 In N/0 21. Workstation/procedure area decontaminated o <br /> /A <br /> supplied* A <br /> In 6. Invoices and log kept for disposable,pre- In 10 22. Chemical disinfectant use I ❑ 0 <br /> 19 11N/A sterilized equipment,backup supplies available* Chemical usi RA C.,U <br /> In N/0 7. Sharps containers supplied,labeled,used and In NNe 23. Disinfectant used sufBcl t contact time VVet O <br /> N/A disposed of correct) * ® /A contact time r a A C, <br /> In N/ 8. Jewelry,tattoo and piercing equipment-storage ❑ N/O 24. Barriers available and used as part of <br /> -NIA and use 1 0 A/A procedure 11 El <br /> In N/0 25. Products applied to skin are single <br /> 0 11 <br /> N/A useldis ensedaseptically <br /> I 0 9. No eating,drinking or smoking-clean clothes In NO 26. Storage of inks,pigments,needles,tubes,etc., <br /> N/ /A <br /> I N/ 0 13 <br /> 10. Hands washed effectively and timely ❑ in N/0 27. Jewelry,Inks,Needles etc approved and used <br /> A <br /> n WO 11. Handwashing facilities properly supplied and ® In 28. Cross-contamination avoided during all phases <br /> 0 13 <br /> N/A accessible,warm potable water* N/A of procedure <br /> n :. .. ., <br /> In /0 12. Personal protective equipment available and 0 ❑ S '9>J ' CEM ' <br /> N used,eyewash station available <br /> In N/0 29. Areas separated/no living or sleeping <br /> N/Aquarters/no animals UX <br /> In N10 13. Branding is completed with no other customers in ® In N/0 30. Floors and walls clean and in good repair, <br /> NIArocedure area /A adequate light <br /> n NIO 14. Customers eighteen(18)years of age or older ® ❑ N/O 31. Workstation,surfaces,including chairs,,etc.in <br /> N/ /A good repair,trash removed fr uentl <br /> I N1 15. Skin prepared for procedure. 13 ® I N/0 32. Permit/registration and required signs posted <br /> NIA N/A <br /> In N/0 16. Client records available-Consent form& In N/0 33. IPCP and employee training records and <br /> NIA questionnaire N/A Hepatitis B vaccination status present <br /> In N/0 17. Aftercare instructions given to client13In N/0 34 Restrooms available,stocked <br /> CY 13 <br /> N/A N/A <br /> Received b (Print): r ec Received by(Signature): Phone: <br /> Special ist Print: J (,L� <br /> Specialist Si nature: Phone: <br /> This report is an Official Notice of Violation.Corrections must be completed in the time specified. <br /> A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) <br /> Page 2 of <br />