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ro Body Art Inspection Report Date: <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E. Hazelton Ave., Stockton, CA 95205 9 <br /> Record: <br /> (209) 468-3420 Program <br /> w .stowora/ehd Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PR0544776 Carrie Blubaugh <br /> PR0546593 Alexis Burks <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) - A sterilization certificate was not available for the Slayer needles with lot <br /> #LU19051233. Submit a copy of the sterilization certificate 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 forms were not signed by the practitioner. Ensure all client <br /> consent forms are signed . <br /> PROVIDE CORRECTIONS OF VIOLATIONS TO THE EHD BY APRIL 7 , 2021 . <br /> NOTES : <br /> 1 . Inspection report emailed to facility owner, Carrie Blubaugh . <br /> 2. Ensure the San Joaquin County Environmental Health Department is notified in writing, within 30 days, when a student is no <br /> longer practicing at the facility. <br /> 3. There are currently 2 practitioners at the facility. <br /> 4. Keep record of purchase for a minimum of 90 days. <br /> 5. Sharps waste should be disposed when container is full or once a year. <br /> DATE : March 24, 2021 PROGRAM RECORD : PR0544775 PROGRAM ELEMENT: 4120 <br /> Reinspecion on/about: A reinspection fee of $152 per hour may be charged. Page 2 of 2 <br /> EH-11 /17 <br />