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Page f E Body Art Inspection Report c Date (MM/DD/YY) >I-co 'I Z County of San Joaquin County, Environmental Health Department Permit Number 1868 E. Hazelton Ave., Stockton CA 95205 (209) 468-3420 www.sioov.org/ehd Permit Type Facility Name Address City Zip Code CT Ta 2 -&ham 9-138 A& c,' 67- 112Q1i Permit/Registration 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 t MW &-,w - In N/0 1. Autoclave is approved and effective -passed ❑ In /0 18. Safe machine design ❑ ❑ /A integrator test N/A ❑ I N10 2. Process of cleaning, labeling, packaging and ❑ ❑ In 10 19. Machines cleaned and disinfected between ❑ N/A sted1zling items correct) N clients ❑ I N/0 3. Autoclave loaded correctly/packages allowed to ❑ ❑ M4:�l 20. Parts replaced between clients - grommets, ❑ N/A dry elastic bands, etc. NIO 4. Integrators used/monthly spore tesNlog 13 13T ibN N/A maintained In /O 21. Workstation/procedure area decontaminated ❑ 3' ❑ N/0 5. Decontamination/sanitation area separate and ❑ ❑ N/A supplied * N/ In N/0 6. Invoices and log kept for disposable, pre- ❑ In N/0 22. Chemical disinfectant used ❑ ❑ N/A sterilized equipment, backupsupplies available * N/A Chemical used: I N/0 7. Sharps containers supplied, labeled, used and❑ ❑ N/0 Q/A 23. Disinfectant used sufficient contact time Wet 11❑ N/A dis osed of correct) * contact timeprovided: 3-S N/0 8. Jewelry, tattoo and piercing equipment - storage ❑ ❑ N/O n/A 24. Barriers available and used as part of ❑13N/A and use rocedure Us W_'Q In N/0 25. Products applied to skin are single ❑ 13 NE E �.... ., IE , n.. s. ,' N/A use/dis nsed ase ticall ❑n NIO 26. Storage of inks, pigments, needles, tubes, etc., 11 I N/0 9. No eating, drinking or smoking - clean clothes ❑ N/ IA In / 10. Hands washed effectively and timely ❑ ❑ N10 27. Jewelry, Inks, Needles etc approved and used ❑ ❑ N/A I N/A UNIO 11. Handwashing facilities properly supplied and 13 E3n N/0 28. Cross-contamination avoided during all phases C] E3I N/A accessible, warm otable water * N/A of procedure N/0 12. Personal protective equipment available and❑ ❑ �' S 9 i , F'� G On 6 N/A used, eyewash station available * L 1" WIN � 11 N' 11" Mq ON ' NOIn 0 29. Areas separated/no living or sleeping ❑ ❑ l afters/no animals * N/0 30. Floors and walls clean and in good repair, [1 13/ In /0 13. Branding is completed with no other customers in ❑ 13I procedure area N/A adequate light N/0 14. Customers eighteen (18) years of age or older ❑ ❑ N/O 31. Workstation, surfaces, including chairs,, etc. in ❑ ❑ N/A N/A good repair; trash removed frequently * N/0 OI 15. Skin prepared for procedure. ❑ 1319 N/0 32. Permit/registration and required signs posted * ❑ 13I N/A In NA) 16. Client records available - Consent form &❑ In N/O 33. IPCP and employee training records and El questionnaire /A He atitiis B vaccination status resent In N/O 17. Aftercare instructions given to clienteeL ❑ In /0 34 Restrooms available, stocked * 11 ❑ N/A N/A 4 z- ( A C t, Received by (Print): Received by (Signature}: Phone: Specialist (P(nt) 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 f E