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i Body Art It* Report nspec The above facility is inspected for compliance with Division V = Violation 104, Date: 113D )1 S N San Joaquin County Environmental Health Department CLEANING AND STERILIZATION C V 1868 E. Hazelton Ave., Stockton, CA 95205 Program Record: 1 j S2OV� I� "R (209) 468-3420 www.siogv.orglend Program 1,� 10 22 Parts replaced between clients - grommets, elastic bands, etc. Element: "t Facility Name Address City Zip Code Forsaken Tattoo 13333 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 V = Violation 104, Part C 15, Chapter 7 of California Health and Safety Code (HSC). = Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION cont C ❑ 1 Autoclave: approved and effective - passed integrator test ❑ ❑ 22 Parts replaced between clients - grommets, elastic bands, etc. ❑ 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 El ® 5 Decontamination/sanitation area separated and supplied appropriately ❑ Chemical used: ❑ 6 Invoices and log kept for disposable, pre -sterilized equipment ❑ ❑ 25. Disinfectant used appropriately/sufficient contact time ❑ ® 7 harps containers labeled, used, and disposed of Sappropriately El Wet contact time provided: ❑ 8 Jewelry, tattoo and piercing equipment - clean and sterilized ❑ El26. Barriers used El PRACTITIONER HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed tical) 11ase ❑ 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, water El30 Cross -contamination avoided during all phases of procedure 11warm ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodborne Pathogen training❑ ❑ 31. Areas separated/no living or sleeping quarters 11 Source: ® 32. Floors and walls clean and inood repair, ad g p equate light ❑ ❑ 14. Appropriate personal protective equipment available and . used ❑ ® 33 Workstation, surfaces, including chairs, armrests, etc. in repair El CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15 Branding is completed with no other customers in procedure area ElEl35. 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 ❑ ❑ 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 El21. Machines cleaned and disinfected between clients El El41. do Received b (Print): Tony Henson Received b Si natur Phone: 209 727-7061 Specialist (Print): Benjamin Escotto Specialist Si nature : (;,Dr, & Phone: (209) 468-3178 Reinspecion on/about: A reinspection fee of $125 per hour may charged. Page 1 of 2 EH -04/2014