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'o aU o Body Art Inspection Report Date(MM/DD/YY) County of San Joaquin County,Environmental Health Department w < Permit Number 1868 E.Hazelton Ave.,Stockton CA 95205 (209)468-3420 www.siaov.org/ehd ` Permit Type 1 Facility Name Address City Zip Code CT Permit/Registration Holder Name Permit Exp.Date Total Time ®I spe tt n Type RISK FACTORS AND I TERVENTIONS 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 ' < , _ gk ENOSRiIETICSMACHIE . } . r� a 34 $ I ,. CLE�tN ..' AVE I�:IZATIQ�t..�� ;��,..��.......=eN�mt�c-... s �,��k �x..��` �;SAF AIVb:$ TIQ �;t�„- our....cos,::• In N/O 1. Autoclave is approved and effective-passed in N/0 18. Safe machine design ❑ 13 ❑ N/A integrator test NIA ❑ In N/0 2. Process of cleaning,labeling,packaging and ❑ 0In N/0 19. Machines cleaned and disinfected between ❑ ❑ NI stedWing items correctly NIA clients In O 3. Autoclave loaded correctly/packages allowed to ❑ ❑ In N/0 20. Parts replaced between clients-grommets, ❑ ❑ Nt dry N/A elastic bands,etc. In ED4. integrators used/monthly spore tesfllog ` ) �1� REVS I GCIQ$S CNTA�III T10 NIA maintained ® ® � � .. .. . ,. f� t�tx IMu In N10 5. Decontamination/sanitation area separate and ❑ ❑ In N/0 21. Workstation/procedure area decontaminated ❑ ❑ N/A supplied* N/A In N/0 6. Invoices and log kept for disposable,pre- ❑ ❑ In N/0 22. Chemical disinfectant used ❑ ❑ N/A sterilized equipment,backu supplies available* N/A Chemical used: In Q 0 7. Sharps containers supplied,labeled,used and ❑ ❑ In N/0 23. Disinfectant used sufficient contact time Wet ❑ ❑ N/A disposed of correct) * N/A contact timeprovided: In N/0 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ In N/0 24. Barriers available and used as part of ❑ ❑ N/A and use N/A procedure > � � � �� '� ' M xwxi � In N/0 25. Products applied to skin are single ❑ ❑ �.,>.. ., FKA Tli[tNEF iEAL7 C� G1 IdE ,... ff ... �,«.,„-! N/A useldis ensedase tical) In N/0 9. No eating,drinking or smoking-clean clothes ❑ ❑ In N/0 26. Storage of inks,pigments,needles,tubs,etc., ❑ ❑ N/A I NIA In N10 10. Hands washed effectively and timely ® ® In N/0 27. Jewelry,Inks,Needles etc approved and used ❑ N/A NIA 13 1 In W 11. Handwashing facilities properly supplied and ❑ In N10 28. Cross-contamination avoided during all phases ❑ ❑ N/A accessible,warm potable water* NIA of procedure In N/0 12. Personal protective equipment available ander BE ST t3US1 $S PTICIvS NIA used,a ewash station available* ❑ ❑MI' CUFIN"SIfrL.)EN'[ � � � � In N10 29. Areas separatedlno living or sleeping ❑ � ... _ r i_ „ =u" N1A uarters/no animals In N10 13. Branding is completed with no other customers in ❑ ® In NIO 30. Floors and walls dean and in good repair, ❑ N/A procedure area N1A ade uate li ht In N/0 14. Customers eighteen(18)years of age or older ❑ ❑ In N10 31. Workstation,surfaces,including chairs,,etc.in ❑ ❑ N/A N/A good repair;trash removed frequently* In N10 15. Skin prepared for procedure. ❑ ❑ In N/0 32, Permit/registration and required signs posted* ❑ ❑ N/A NIA In M 16. Client records available-Consent form& ❑ ❑ In N/0 33. IPCP and employee training records and ❑ N/A uestionnaire N/A Hepatitis B vaccination status resent In 0 17. Aftercare instructions given to client ❑ F13 In N/O 34 Restrooms available,stocked* ❑ ❑ N/ I NIA Received by(Print)' Received by(Signature): Phone: Specialist(Print)' Specialist(Signature): Phone: This report is an Official Notice of Violation.Corrections must be completed in the time specified. R reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page / of