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'" gso, Body Art InspeC Report Date: I V San Joaquin County Environmental Health Department C ❑ 1 Autoclave: approved and effective - passed integrator Program El 22. 1868 E. Hazelton Ave., Stockton, CA 95205 Record: S e-oo9 1A P CippRa� (209) 468-3420 www.siogv.org/ehd Program (.t 10 PREVENTING CROSS -CONTAMINATION Element: 3. Facility Name Address City Zip Code Forsaken Tattoo 13500 hwy. 88 Lockeford 95237 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Tony Henson Appropriate chemical disinfectant used Final Consult. The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). ElChemical V = Violation C = Corrected On Site used: V I CLEANING AND STERILIZATION C I V I MACHINE SAFETY AND SANITATION cont.) C ❑ 1 Autoclave: approved and effective - passed integrator El 22. Parts replaced between clients - grommets, elastic bands, etc. E]test El 2' Items washed, disinfected, packaged, labeled, and sterilized ❑ PREVENTING CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ ❑ 4. Integrators used/monthly spore test/log maintained ❑ ❑ 24. Appropriate chemical disinfectant used ® 5 Decontamination/sanitation area separated and supplied ro riatel appropriately ElChemical used: ❑ 6. 6' Invoices and log kept for disposable, pre -sterilized equipment El 25. Disinfectant used appropriately/sufficient contact time ❑ ® 7'E]aro Sharps containers labeled, used, and disposed of appropriately Wet contact time provided: 8 Jewelry, tattoo and piercing equipment - clean and El El 26. Barriers used Elsterilized PRACTITIONER HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed aseptically ❑ 9. No eating, drinking or smoking - clean clothes ❑ ❑ 28. Storage of inks, pigments, needles, tubes, etc. ❑ ❑ 10. Hands washed effectively and timely ❑ ❑ 29. Jewelry, Inks, Needles etc approved and used correctly ❑ ® 11. Handwashing facilities properly supplied and accessible, warm water 30Cross-contamination ' avoided during all phases of procedure ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodborne Pathogen training ❑ ❑ 31. Areas separated/no living or sleeping quarters ❑ Source: ❑ 32. Floors and walls clean and in good repair, adequate light ❑ ❑ 14 Appropriate personal protective equipment available and used El El 33' Workstation, surfaces, including chairs, armrests, etc. in good repair CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in rocedure area El® 35. Operation and employee training records present ❑ ❑ 16. Customers eighteen (18) years of age or older ❑ COMPLIANCE AND ENFORCEMENT ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s) submitted for review ❑ El 18. Client records approved and available - Consent form and questionnaire El 37. Permits obtained and available ❑ ❑ 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. ❑ Received b (Print): Tony Henson Received by (Signature): &46Lw Phone: (209) 727-7061 Specialist (Print): Benjamin Escotto, Sr REHS Specialist Si nature : Phone: 209 468-3178 Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015