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Body Art Inspection Report Date(MMIDDIYY) 1 y County of San Joaquin County,Environmental Health Department 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number , (209)468-3420 www.siaov.om/ehd Permit Type /f Facility Name Address City Zip Code CT Permit/R istration Holder Name Permit Exp.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/O=Not Observed N/A=Not Applicable COS=Corrected On Site _ SAN T. .4 t) �.,.ER *.,EN Ct?SMETICS ft�0.CHINE `�'s £ - ...3».a A laSA o,1IfJ In A /0 1. Autoclave is approved and effective-passed ❑ ❑ In NIO 18. Safe machine design 13 IA int rotor test N/A In /O 2. Process of cleaning,labeling,packaging and ❑ ❑ In N/0 19. Machines cleaned and disinfected between ❑ / stediziin items correct) A clients In 0 3. Autoclave loaded correctly/packages allowed to El ❑ n /0 20. Parts replaced between clients-grommets, ❑ 13NI d NIA elastic bands,etc. In 0 4. Integrators used/monthly spore tesMog / maintained 13 ❑ '. In-'R0 5. Deoontamination/sanitation area separate and ❑ ❑ In /0 21. Workstation/procedure area decontaminated ❑ ❑ / supplied In N/0 6. Invoices and log kept for disposable,pre- 9/A N/0 22. Chemical disinfectant used N/A sterilized equipment,backu supplies available* ® Chemical used: a QN/O 7. Sharps containers supplied,labeled,used and 13 In WO 23. Disinfectant used sufficient contact time Wet [133 ❑ N/A disposed of corrects * /A contact timeprovided:30 yw,A In N/O 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ NIO 24. Barriers available and used as part of ❑ ❑ N/A and use N/A procedure � � � � n NIO 25. Products applied to skin ars single ❑ ❑ 0, 1111,101-0091, N/A use/dispensed ensed ase tical) l N/0 9. No eating,drinking or smoking-dean clothes ❑ ❑ N/0 26. Storage of inks,pigments,needles,tubes,etc., ❑ ❑ N/A N/A NA NIO 10. Hands washed effectively and timely ❑ ® I NIO 27. Jewelry,Inks,Needles etc approved and used NIA In N/0 11. Handwashing facilities properly supplied and ( N/0 28. Cross-contamination avoided during all phases N/A accessible,warm table water* El N/A of procedure ❑ ❑ N/O 12. Personal protective equipment a«aiiable and ❑ `� M S`A!E p CTIA #fi � . N/A used,eyewash station available CUIOAIIE Sll)Egftin 0 29. Areas separated/no living or sleeping KRA /A guarters/no animals* ❑ ❑ In 0 13. Branding is completed with no other customers in11 ❑ &NO 30. Floors and walls dean and in good repair, ❑ ❑ procedure area A adequate light* 10 14. Customers eighteen(18)years of age or older ❑ ❑ &AIO 31. Workstation,surfaces,including chairs,,etc.in ❑ ❑ N/A N/A good repair;trash removed frequently I N/0 15. Skin prepared for procedure. ❑ ❑ n N/0 32. Permit/registration and required signs posted* ❑ ❑ N/A A NN/O 16. Client records available-Consent form& 13 In N/0 33. IPCP and employee training records and n !A uestionnaire NIA I He atitiis B vaccination status present In N/0 17. Aftercare instructions given to client ® NIO 34 Restrooms available,stocked* ❑ ❑ NIA NIA Received by(Print): Received by(Signature): Phone: Specialist(Print): Specialist(Signature): Phone: This report is an Official Notice of Violation.Corrections must be completed in the time specified. A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page I of 1v`