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A R <br /> p Lilly <br /> " Body Art Inspec Report Date: 6/ <br /> 7-9 ZO) <br /> San Joaquin County Environmental Health Department <br /> Program <br /> ¢. g <br /> ti. <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: <br /> (209)468-3420 Program <br /> Q<IFOR�'�www.siogv.orq/ehd Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> Carol Chao <br /> Alanna Chao <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) <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 <br /> 19. At the completion of the procedure, the practitioner shall provide postprocedure instructions that include all elements listed in <br /> Form B. HSC 119308(b) <br /> Correct all violations noted above by July 8, 2017. <br /> Notes: <br /> 1.) Facility has been approved to open. <br /> 2.) The 2 rooms at the north end of the hallway upstairs have been approved for body art use. Alanna Chao and Carol Chao <br /> are currently the only registered practitioners on site and will be operating out of the north room. The south room is not <br /> currently being used for body art. Only registered practitioners may perform body art on site in the 2 approved rooms. <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 2 of 2 <br /> EH-03/2015 <br />