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Body Art Inspection Report <br />j�County of San Joaquin County, Environmental Health Department <br />i 1868 E. Hazelton Ave., Stockton CA 95205 <br />(209) 468-3420 www.siaov.ora/ehd <br />9GfF0�� <br />Facility Name <br />ForsC46n Tot�c <br />Permit/Registration Holder Name <br />Tn n (A 14C_C1& 6, <br />Address <br />rl 13ub3 41A)rA- <br />City Zip Code <br />t o 4zcto )a 9 S 7_3'� <br />Permit Exp. Date Total Time <br />Date (MM/DD/YY) 3�S �3 <br />Permit Number (, 1 L <br />Permit Type 41 a 1 <br />SCT um 0M141fl, <br />Inspection Type <br />F1 nwl tonsx&-&I-rOn <br />RISK FACTORS AND INTERVENTIONS <br />Risk factors are improper practices or procedures identified as contributing factors of cross -contamination. <br />Interventions are control measures to prevent cross -contamination and transfer of pathogens from one person to another. <br />In = In Compliance Out = Not in Compliance N/O = Not Observed N/A = Not Applicable COS = Corrected On <br />In 10 1 <br />1. Autoclave is approved and effective - passed <br />0 <br />0 <br />/A <br />integrator test <br />In N/0 <br />2. Process of cleaning, labeling, packaging and <br />0 <br />0 <br />/ <br />sterlizling items correct) <br />In/0 <br />3. Autoclave loaded correctly/packages allowed to <br />❑ <br />❑ <br />N/ <br />dry <br />In N/0 <br />4. Integrators used/monthly spore test/log <br />❑ <br />0 <br />NIA <br />maintained <br />In N/0 <br />5. Decontamination/sanitation area separate and <br />❑ <br />0 <br />NIA <br />supplied * <br />In N/0 <br />6. Invoices and log kept for disposable, pre - <br />❑ <br />❑ <br />/A <br />sterilized equipment, backu supplies available <br />In N10 <br />7. Sharps containers suppl, used and <br />0 <br />0 <br />NIA <br />disposed of correct) <br />II <br />ZN7 <br />8. Jewelry, tattoo and pier ' ' ent- storage <br />0 <br />0 <br />N/A <br />and use <br />PRACTITIONER HEALTH'AND HYGIENE t. -, <br />In yo 9. No eating, drinking or smoking - clean clothes 0 0 <br />!A <br />In /0 10. Hands washed effectively and timely 0 0 <br />A <br />In N/0 11. Handwashing facilities properly supplied and0 <br />accessible, warm potable water * 04 <br />In VO 12. Personal protective equipment available and 0 O <br />/A I used. evewash station available' <br />In ICS <br />13. Branding is completed with no other customers in <br />0 <br />0 <br />N/procedure <br />area <br />In <br />14. Customers eighteen (18) years of age or older <br />0 <br />0 <br />N/A <br />Chemical used: Sa I <br />n N/0 <br />15. Skin prepared for procedure. <br />0 <br />0 <br />N/A <br />contact time provided: i� `��� <br />In N/0 <br />16. Client records available - Consent form & <br />❑ <br />0 <br />NIA <br />I questionnaire <br />In N/0 <br />17. Aftercare instructions given to client <br />❑ <br />0 <br />N/A <br />use/dispensed aseptically <br />Sem Le -.V �CL <br />nllr0 <br />�' k.r 1TATT00 DPMi4NENTCbSMETICSMACHINE� <br />�,1 .'��'� SAF ;AND SANITATION � ; .� r },f5 s . .our•'' cos <br />I N/0 18. Safe machine design 0 0 <br />N/A <br />I N/O 19. Machines cleaned and disinfected between 0 <br />N/A clients <br />NI0 20. Parts replaced between clients - grommets, 0 0 <br />N/A elastic bands, etc. <br />N/0 <br />21. Workstation/procedure area decontaminated <br />0 <br />❑ <br />NIA <br />uarters/no animals * <br />NIO <br />22. Chemical disinfectant used <br />❑ <br />❑ <br />N/A <br />Chemical used: Sa I <br />14 NN/0 <br />23. Disinfectant used sufficient contact time Wet <br />0 <br />0 <br />/A <br />contact time provided: i� `��� <br />I N/0 <br />24. Barriers available and used as part o <br />❑ <br />❑ <br />A <br />procedure * <br />I NIO <br />25. Products applied to skin are single_14 <br />❑ <br />❑ <br />/A <br />use/dispensed aseptically <br />In N/0 <br />26. Storage of inks, pigments, needles, tubes, etc., <br />❑ <br />❑ <br />/A <br />In /0 <br />27. Jewelry, Inks, Needles etc approved and used <br />0 <br />0 <br />/A <br />jIn N10 <br />28. Cross -contamination avoided during all phases <br />❑ <br />❑ <br />N/A <br />of procedure <br />�XWN/Ci i29. <br />Areas separated/no living or sleeping <br />❑ <br />❑ <br />N/A <br />uarters/no animals * <br />n NIO <br />30, Floors and walls clea ood repair, <br />El <br />11 <br />ade uate li ht * D <br />I /0 <br />31. Workstation, surfaces, ' lud' chairs, , etc. in <br />❑ <br />❑ <br />N/A <br />good repair, trash removed fre Lent) <br />In N/0 <br />32. Permit/registration and required signs posted * <br />0 <br />0 <br />N/A <br />In N10 <br />33. IPCP and employee training records and <br />0 <br />N/A <br />He atitiis B vaccination status present <br />In N/0 <br />34 Restrooms available, stocked * <br />0 <br />Phone: <br />Specialist (Print): Specialist (Signature): Phone: <br />❑This report is an Official Notice of Violation. Corrections must be completed in the time specified. <br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date (on or about) <br />Page of 3 <br />