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"� Y p Body Art Ins ectim Report / <br /> �' 1 P Date: �l.2S/aZC7 <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 <br /> \\ Record: <br /> (209)468-3420 <br /> Program <br /> www.siogv.org/ehd <br /> Element: <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> Erica Green-Frese-Permit&BBP posted(BBP exp. <br /> PR0541622 9/25/20 <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)—The sterilization certificate was not available for MadLuv blades with lot <br /> #MB1920125. Provide a copy of the sterilization certificate to the EHD when received from the manufacturer. <br /> 7. The sharps waste container shall be within arm's reach and labeled with the word "sharps waste" or with the biohazard symbol <br /> and the word "Biohazard". Sharp waste containers shall be disposed by a licensed waste hauler or approved mail back system. <br /> Documentation of proper disposal shall be maintained for 3 years. HSC 119314(e)—The sharps waste has not been <br /> disposed of in 3 years.Ensure the sharps waste is disposed of at leaste once a year. Provide copy of receipt after <br /> disposal of sharps waste 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 medical questionnaire did not include all of the information from Form B. <br /> Include the following information to the medical questionnaire: <br /> - History of hemophilia or other bleeding disorders. <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. HSG 119303—A few of the client consent forms were missing a copy of the client identification <br /> card and one consent form was not signed. Ensure a copy of the client identification card is kept with the consent form <br /> and all information on the consent form is complete. <br /> 35. Operation and employee training records shall be maintained for 3 years and made available for inspection. A written <br /> Infection Prevention and Control Plan (IPCP) shall be maintained, followed and updated. HSC 119313—The IPCP did not <br /> include the set-up and tear down of the workstation (#D-3). -Corrected on site. <br /> Correct all violations by March 13, 2020, submit corrections to the EHD. <br /> NOTES: <br /> 1.The current Bloodborne Pathogen Training Certificate was not posted. Practitioner corrected on site. <br /> 2.A copy of client identification was not copied due to facility printer not working. <br /> 3.Sharps Solution is used for sharps disposal. <br /> Reinspecion on/about: A reinspection fee of$152 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />