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Body Art Inspection Report Date(MM/DD/YY) County of San Joaquin County,Environmental Health Department - 3 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number ® l6 (209)468-3420 www.sioov.org/ehd � Permit Type Li Facility Name Address City Zip Code CT toy"yic-, t"V_ 16jA c:2 c114- `. .Y-ry •k_ &4- q s,5tCv 3 ..San 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 TATTOO AND PERMANENT COSMETICS MACHINE CLEANING AND STERILIZATION Four cos SAFETYAND SANITATION our cos In N/0 1. Autoclave is approved and effective-passed ❑ In NIO 18. Safe machine design ❑ ❑ NIA irate ratortest NIA In 1 2. Process of cleaning,labeling,packaging and ❑ ❑ In NIO 19. Machines cleaned and disinfected between 11 N sterliziin items correct) NIA clients In NIO 3. Autoclave loaded correctly/packages allowed to CWL ❑ In NIO 20. Parts replaced between clients-grommets, ❑ ❑ N/A dry N/A elastic bands,etc. N/0 4. Integrators used/monthly spore test/log ❑ ❑ PREVENTING CROSS-CONTAMINATION. NIA maintained In NIO 5. Decontamination/sanitation area separate and ❑ In N/0 21. Workstation/procedure area decontaminated ❑ 11 NIL_ supplied* PQ NIA In ! 6. Invoices and log kept for disposable,pre- ❑ ❑ In NIO 22. Chemical disinfectant used ❑ ❑ sterilized equipment,backu supplies available N/A Chemical used:&Ati N/O 7. Sharps containers supplied,labeled,used and ❑ ❑ In N/0 23. Disinfectant used sufficient contact time Wet ❑ ❑ N/A disposed of correct) * IA contact time rovided: In N/0 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ 10 24. Barriers available and used as part of ❑ ❑ N/A and use /A procedure In NIO 25. Products applied to skin are single ❑ PRACTITIONER HEALTH AND HYGIENE N/A use/dispensed ase tical) In JU0 9. No eating,drinking or smoking-clean clothes ❑ ❑ NIO 26. Storage of inks,pigments,needles,tubes,etc., ❑ ❑ N/A NIA In KO 10. Hands washed effectively and timely ❑ ❑ In N/0 27. Jewelry,Inks,Needles etc approved and used ❑ ❑ NI N/A �n N10 11. Handwashing facilities properly supplied and ❑ ❑ In NIO 28. Cross-contamination avoided during all phases ❑ ❑ IA accessible,warm potable water* NIA of procedure N/0 12. Personal protective equipment available and ❑ ❑ BEST BUSINESS.PRACTICES NIA used,eyewash station available sCUSTOMERSICLIENTS" In N/0 29. Areas separated/no living or sleeping ❑ ❑ quarters/no animals In 0 13. Branding is completed with no other customers in ❑ ❑ UTT N10 30. Floors and walls clean and in good repair, ❑ ❑ A procedure area N/A adequate light In NIO 14. Customers eighteen(18)years of age or older ❑ ❑ GIA N/0 31. Workstation,surfaces,including chairs,,etc.in ❑ ❑ ood repair;trash removed frequently* 1 N/0 15. Skin prepared for procedure. ❑ ❑ N/0 32. Permit/registration and required signs posted" ❑ ❑ NIA I IA In N/0 16. Client records available-Consent form& JgL ❑ n NIO 33. IPCP and employee training records and ❑ ❑ N/A questionnaire N/A He atitiis B vaccination status present In NIO 17. Aftercare instructions given to client ❑ n N/0 34 Restrooms available,stocked* ❑ ❑ N/A A Received by(Print): Received by(Signature): Phone: Specialist(Print): Specialist(Signature): Phone: F] 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 3