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i <br />,o Qul -•'� Body Art Inspection Report Date (MM/DD/YY) {yt <br />County of San Joaquin County, Environmental Health Department M ®0'n <br />� I b, <br />< 1868 E. Hazelton Ave., Stockton CA 95205 Permit Number <br />(209) 468-3420 www.sigov.om1ehd 1 �� <br />Permit Type <br />Qt�Fo a <br />Facility Name Address City Zip Code CT <br />IM1) 0,&toy FT*tat, 'I'tIA tau sucl,.�, As s1- Gslum Sun 501.gu4'% <br />Permit/Registration Holder Name Permit Exp. Date Total Time Inspection Type <br />C�kc e,r S A-UPi rw— <br />RISK FACTORS AND INTERVENTIONS <br />Risk factors are improper practices or procedures identified as contributing factors of cross -contamination. <br />Interventions are control measures to prevent cross -contamination and transfer of pathogens from one person to another. <br />In = In Com liance Out = Not in Compliance N/0 = Not <br />Observed <br />N/A <br />= Not Applicable COS = Corrected On Site <br />N/O <br />18. Safe machine design h 0 0 <br />In 0 <br />1. Autoclave is approved and effective- passed <br />11 <br />/A <br />integrator test <br />N/A <br />In 0 <br />2. Process of cleaning, labeling, packaging and11In <br />13 <br />/0 <br />1 <br />19. Machines cleaned and disinfected between <br />0 <br />11 <br />A <br />steriiziin items correct) <br />clients <br />In <br />3. Autoclave loaded correctly/packages allowed to <br />13 <br />❑ <br />In W <br />20. Parts replaced between clients -grommets, <br />dry <br />NIA <br />elastic bands, etc. <br />4. Integrators used/monthly spore testAog� <br />maintained <br />in0 <br />21. Workstation/procedure area decontaminated <br />11 <br />I <br />5. Decontamination/sanitation area separate and <br />0 <br />❑ <br />/A <br />supplied * <br />I <br />In N/0 <br />6. Invoices and log kept for disposable, pre <br />El <br />In N/O <br />22. Chemical disinfectant used <br />0 <br />13 <br />N/A <br />sterilized equipment, backup supplies available * <br />A <br />Chemical used: M aAZd <br />In N/O <br />7. Sharps containers supplied, labeled, used and <br />JR <br />CZXIO <br />23. Disinfectant used sufficient contact time Wet <br />11 <br />0 <br />/A <br />I disposed of correctly * <br />N/ <br />contact timeprovided: <br />Jewelry, tattoo and piercing equipment – storage <br />0 <br />❑ <br />In / <br />24, Barriers available and used as part of <br />® <br />13 <br />and use <br />rocedure <br />25. Products applied to skin are single <br />t <br />ft 0 . E ;.. .. .IE , .. , �: w <br />useldis nsed aseptically <br />No eating, drinking or smoking - clean clothes <br />❑ <br />0 <br />tN <br />26. Storage of inks, pigments, needles, tubes, etc., <br />Hands washed effectively and timely <br />27. Jewelry, Inks, Needles etc approved and used <br />0 <br />13 <br />In N/0 <br />11. Handwashing facilities properly supplied and <br />p( <br />❑ <br />In jdl <br />28. Cross -contamination avoided during all phases <br />13 <br />13 <br />/A <br />accessible, warm potable water * <br />� <br />NIA <br />of procedure <br />In N/0 <br />12. Personal protective equipment available and <br />❑ <br />❑E <br />EaP C �C ry <br />N/A <br />used, eyewash station available <br />S <br />In 0 <br />29. Areas separated/no living or sleeping <br />E3 <br />11 <br />N/Aquarters/no <br />animals <br />In NIO <br />13. Branding is completed with no other customers in <br />14/0 <br />30. Floors and walls clean and in good repair, <br />/A <br />procedure area <br />A <br />adequate light * <br />In <br />14. Customers eighteen (18) years of age or older <br />® <br />n IO <br />31. Workstation, surfaces, including chairs, , etc. in <br />11 <br />0 <br />N/A <br />good repair; trash removed frequently * <br />InN <br />15. Skin prepared for procedure. <br />0 <br />® <br />In N/0 <br />32. Permit/registration and required signs posted <br />In N/0 <br />16. Client records available - Consent form & <br />0 <br />in N/0 <br />33. IPCP and employee training records and <br />0 <br />N/A <br />questionnaire <br />N/A <br />Hepatitis B vaccination status present <br />In N/0 <br />17. Aftercare instructions given to client <br /><JW N/0 <br />34 Restrooms available, stocked <br />0 <br />13 <br />N/A <br />N/A <br />Received b (Print): Received b Si nature : Phone: <br />91 fl– <br />Specialist (Print): Specialist (Signature): Phone: <br />This report is an Official Notice of Violation. Corrections must be completed in the time specified. <br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. <br />Pagel. of 3 <br />Reinspection Date (on or about) <br />