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P°"`" Body Art Inspect*Report • date: 10/I G /)q <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,GA 95205 Record: Neo 6q 103 O <br /> (209)468-3420 Program / <br /> cq<rciiRc'P www.siogv.org/ehd Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> Robert Fredericksen-BBP and permit posted.BBP <br /> PR0541071 ex .9-4-20. <br /> Shaunessey Fredericksen-BBP posted,permit not <br /> PRO543616 present.BBP exp.4-13-20. <br /> Observations and Corrective Actions: <br /> 6. A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and <br /> client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone <br /> sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a <br /> minimum of 90 days after use. HSC 119315(f)—Sterilization certificates were not available for the needles or blades. <br /> Provide EHD with sterilization certificates for lot#09-18 and lot#03-19 needles and lot#ISO 9002 blades. <br /> 7. The sharps waste container shall be within arm's reach and labeled with the word "sharps waste"or with the biohazard <br /> symbol and the word"Biohazard". Sharp waste containers shall be disposed by a licensed waste hauler or approved mail back <br /> system. Documentation of proper disposal shall be maintained for 3 years. HSC 119314(e). —The sharps container was full <br /> and has not been disposed of for over a year. Provide evidence of recent sharps disposal to the EHD. <br /> 18. The facilities client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. HSC 119303. —The client consent form and the medical questionnaire did not include all the <br /> required information.The client consent form must include: <br /> For Robert: <br /> - The description of what the client should expect following the procedure. <br /> - Notice that inks are not FDA approved and health consequences are unknown. <br /> ForShaunessey: <br /> - Notice that inks are not FDA approved and health consequences are unknown. <br /> The medical questionnaire must include the following: <br /> For Robert: <br /> - Client status regarding pregnancy. <br /> ForShunessey: <br /> - History of herpes infection at the procedure site. <br /> - History of diabetes. <br /> - History of allergic reactions to latex. <br /> - History of allergic reactions to antibiotics. <br /> - History of hemophilia or other bleeding disorders. <br /> - History of cardiac valve disease. <br /> - Requirements for antibiotics prior to surgery or dental procedures. <br /> - Other risk factors for blood borne pathogens. <br /> Reinspecion on/about: A reinspection fee of$152 per hour may be charged. Page 2 of 3 <br /> EH-11/17 n ' <br /> V <br />