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Facility Name Address City Zip Code Forsaken Tattoo 13463 hwy 88 Lockeford 95237 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Anthony G Henson 6/30/14 Routine 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 Body Art Inspecol Report Date: S h3 �l 2 2' Q A San Joaquin County Environmental Health Department Program ❑ • • 1868 E. Hazelton Ave., Stockton, CA 95205 Record: PQ�75 S 1 `cq�,FOR�`P (209) 468-3420 Program 2 www.siogv.orq/ehd Element: (410.1 PREVENTING CROSS -CONTAMINATION Facility Name Address City Zip Code Forsaken Tattoo 13463 hwy 88 Lockeford 95237 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Anthony G Henson 6/30/14 Routine 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 I 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 testilog maintained ❑ ❑ 24. Appropriate chemical disinfectant used ❑ ❑ 5. Decontamination/sanitation area separated and supplied appropriately ❑ Chemical used: ® 6• Invoices and log kept for disposable, pre -sterilized equipment El El25. Disinfectant used appropriately/sufficient contact time El7 ❑ Sharps containers labeled, used, and disposed o f appropriately ❑ Wet contact time provided: ❑ 8 Jewelry, tattoo and piercing equipment - clean and sterilized El El26. Barriers used ❑ HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed aseptically ElPRACTITIONER ❑ 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,Cross-contamination warm water F-1 ❑ 30' avoided during all phases of procedure F1 ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodbome Pathogen trainingE][jEl31. 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 F1ElWorkstation, 33. surfaces, including chairs, armrests, etc. in ood repair CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in rocedure area [:1 [j35. 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 ❑ ❑ 37. Permits obtained and available E] ❑ 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): AnthonyHenson Received b Si natur . .Gv Phone -70&1 Specialist (Print): Benjamin Escotto Specialist (Signature): Phone: (209) 468-3178 Reinspecion on/about: A reinspection fee of $125 per hour may charged. Page 1 of 2 EH -04/2014