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Paged -of -6 <br />Body Art Inspection Report <br />Date (MM/DD/YY) <br />County of San Joaquin County, Environmental Health Department <br />Permit Number <br />1868 E. Hazelton Ave., Stockton CA 95205 <br />(209) 468-3420 www.sicjov.QLqLqhd <br />Permit Type <br />Facility Name <br />Address city <br />Zip Code CT <br />6LnGtr_ <br />1jq_%1QL1 <br />Sarl L,44 <br />Permit/Registration Holder Name Permit Exp. Date <br />Total Time Inspection 'Type <br />/s <br />-LnL�=c It link <br />RISK FACTORS AND INTERVENTIONS <br />V <br />Risk factors are improper practices or procedures identified <br />as contributing factors of cross -contamination. <br />Interventions are control measures to prevent cross -contamination <br />and transfer of pathogens from one person to another. <br />In = In Compliance Out = Not in Compliance N/O = Not <br />Observed <br />N/A <br />= Not Applicable COS = Corrected On Site <br />15 <br />mc 0 <br />ER1 110"'o'sm <br />In N/O <br />1. Autoclave is approved and effective - passed <br />E3 <br />N/0 <br />NA <br />18. Safe machine design <br />0 <br />0 <br />NIA <br />integrator test <br />In N/O <br />2. Process of cleaning, labeling, packaging and <br />1:3 <br />(jD/N/0 <br />19. Machines cleaned and disinfected between <br />13 <br />0 <br />NIA <br />stediziing items correctly <br />P47, <br />-,,VA <br />clients <br />In N/O <br />3. Autoclave loaded corredy/packages allowed to <br />1:3 <br />(6YN10 <br />20. Parts replaced between clients - grommets, <br />0 <br />0 <br />NIA <br />dry <br />N/A <br />elastic bands, etc. <br />In N/0 <br />4. Integrators used/monthly spore testilog <br />ELI <br />[3 <br />NIA <br />maintained <br />In N/O <br />5. Decontamination/sanitation area separate and <br />13 <br />Inr <br />21. Workstation/procedure area decontaminated <br />0 <br />0 <br />supplied <br />1 <br />N/O <br />6. Invoices and log kept for disposable, pre- <br />13 <br />13 <br />In N/O <br />9 <br />22. Chemical disinfectant used 0)0h2�i� <br />0 <br />0 <br />rA" <br />N/A <br />sterilized tguipment, backup supplies available <br />N/A <br />Chemical used: <br />1n N/0 <br />7. Sharps containers supplied, labeled, used and <br />0 <br />In WO <br />23. Disinfectant used sufficient contact time Wet <br />13 <br />13 <br />NIA <br />disposed of correctly * <br />F'*t <br />N/A <br />contact time provided: <br />140 ._ . / <br />8. Jewelry, tattoo and piercing equipment- storage <br />0 <br />- <br />0 <br />_7FX1,0 <br />24. Barriers available and used as pad of <br />13 <br />13 <br />and use <br />-N/A <br />procedure <br />" <br />NOT ANNE INE' <br />i <br />N10 <br />25. Products applied to skin are singe <br />13 <br />13 <br />W r H <br />N/A <br />useldispensed aseptically <br />In N/O <br />9. No eating, drinking or smoking - dean clothes <br />4m4 0 <br />&N/O <br />26, Storage of inks, pigments, needles, tubes, etc., <br />0 <br />13 <br />N/&-, <br />NIA <br />In A)' <br />10. Hands washed effectively and timely <br />11® <br />27. Jewelry, Inks, Needles etc approved and used <br />0 <br />13 <br />N <br />In N10 <br />11. Handwashing facilities properly supplied and <br />0 <br />In28. <br />Cross -contamination avoided during all phases <br />I <br />13 <br />0 <br />AIA <br />accessible, warm potable water <br />NO' <br />of procedure <br />n 0 <br />12. Personal protective equipment available and <br />0 0 <br />used, eyewash station available <br />60800R.811AIE,11 <br />29. Areas separated/no living or sleeping <br />quartersino animals <br />In XO <br />13. Branding is completed with no other customers in <br />0 <br />0 <br />Iii-NIO <br />30. Floors and walls dean and in good repair, <br />0 <br />PA) <br />procedure area <br />N/A <br />adequate light * <br />0 <br />14. Customers eighteen (18) years of age or older <br />EI <br />13 <br />In N/0 <br />31. Workstation, surfaces, including chairs, , etc. in <br />-0 <br />/A _ <br />N/A <br />I good repair; trash removed frequently * <br />In <br />NP <br />15. Skin prepared for procedure, <br />0- <br />In N/0 <br />32. Permit/registration and required signs posted <br />0 <br />0 <br />In N/O <br />16. Client records available - Consent form & <br />13 <br />33. IPCP and employee training records and <br />A21 <br />0 <br />NIA <br />questionnaire <br />NIA <br />Hepatitis B vaccination status present <br />In N/O <br />17. Aftercare instructions given to clientIn <br />01 <br />N/0 <br />34 Restrooms available, stocked <br />0 <br />0 <br />N/A <br />NIA <br /><;ee- 142w( <br />U <br />Received by <br />(Print): Received by (Signature): <br />Phone: <br />Specialist (Print): <br />Specialist (Signature): <br />Phone: <br />This report is an Official Notice of Violation. Corrections must be completed in <br />the time specified. <br />A reinspection <br />fee may be charged if violations noted on this report are not corrected <br />by the <br />reinspection date. Reinspection Date (on or <br />about) <br />Paged -of -6 <br />