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Qul" Body Art Inspeck Report Date: %%N/IS San Joaquin County Environmental Health Department Program 1868 E. Hazelton Ave., Stockton, CA 95205 Record: 4QOUl1 13110 c P (209) 468-3420 Pro 9��F•CiRa` www.sram ioov.oro/ehd 9 u10Z Element: 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 Initial Consult. The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). V = Violation C = Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator Parts replaced between clients - grommets, elastic bands, test El ❑ 22' etc. ❑ ❑ 2 Items washed, disinfected, packaged, labeled, and sterilized El CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ ❑ 4. Integrators used/monthly spore testllog maintained ❑ [1 24. Appropriate chemical disinfectant used Elappropriately ® 5 Decontamination/sanitation area separated and supplied ❑ Chemical used: ❑ 6 Invoices and log kept for disposable, pre -sterilized equipment El El25. Disinfectant used appropriately/sufficient contact time ❑ ❑ 7 Sharps containers labeled, used, and disposed of appropriately ElWet contact time provided: ❑ 8 Jewelry, tattoo and piercing equipment - clean and sterilized ❑ ❑ 26. Barriers used ❑ PRACTITIONER HEALTH AND HYGIENE F-1 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 ❑ ® 71. Handwashing facilities properly supplied and accessible, warm water El ❑ 30' Cross -contamination avoided during all phases of El ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodborne Pathogen trainingE]❑ 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 ❑ ❑ 33 Workstation, surfaces, including chairs, armrests, etc. in ood re air Elused CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in rocedure area El El 35. Operation and employee training records present El ❑ 16. Customers eighteen (18) years of age or older ❑ COMPLIANCE AND ENFORCEMENT ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s) submitted for review ❑ ❑ 18 Client records approved and available - Consent form and uestionnaire ❑ El 37. Permits obtained and available El ❑ 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ r[] 20. Safe machine design El ❑ 40. Closure El ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. 1 ❑ Received b Print): Tony Henson Received b Si nature Phone: 209 727-7061 Specialist (Print : Benjamin Escotto, Sr REHS Specialist (Signature): Phone: 209 468-3178 Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015