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oa°"s"•• Body Art Inspection Report <br />County of San Joaquin County, Environmental Health Department <br />w 7� 1868 E. Hazelton Ave., Stockton CA 95205 <br />(209) 468-3420 www.siaov.ora/ehd <br />F cility Name Address 1 City Zip Code <br />�` �a O 3J 1�u? l.a <br />Permit/Registration Holder Name Permit Exp. Date Total Time <br />Date (MM/DD/YY) als '3 <br />Permit Number S S <br />IB <br />Permit Type ®3 <br />CT <br />J- <br />Inspection Typa <br />a'%"1i'1-&AM'AAWIT <br />In N/0 16. Client records available -Consent form &0 0 In N/0 33. IPCP and employee training records and 0 0 <br />N/A questionnaire N/A He atitiis B vaccination status present <br />In N/0 17. Aftercare instructions given to client 0 0 In N/0 34 Restrooms available, stocked * 0 0 <br />N/A NIA <br />S"e, Ck 14 <br />Received by (Print): Received by (Signature): 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 />Pagel of 3 <br />RISK FACTORS AND <br />INTERVENTIONS <br />Risk factors are improper practices or procedures <br />identified <br />as contributing factors of cross -contamination. <br />Interventions are control measures to prevent cross -contamination <br />and transfer of pathogens from one person to another. <br />In= In Com fiance Out = Not in Compliance N/0 <br />= Not <br />Observed <br />N/A = Not Agelicable COS = Corrected On Site <br />t <br />1. Autoclave is approved and effective - passed <br />0 <br />0 <br />In N/0 18. Safe machine design <br />In N/0 <br />N/A <br />integrator test <br />NIA <br />In N/O <br />2. Process of cleaning, labeling, packaging and <br />0 <br />0 <br />In N/0 <br />19. Machines cleaned and disinfected between <br />0 <br />0 <br />N/A <br />sterlizilng items correct) <br />N/A <br />clients <br />In N/0 <br />3. Autoclave loaded correctly/packages allowed to <br />0 <br />In N/0 <br />20. Parts replaced between clients - grommets, <br />0 <br />0 <br />N/A <br />dry <br />NIA <br />elastic bands, etc. <br />In NIO <br />4. Integrators used/monthly spore testAog <br />� ' E. C t sssO <br />NIA <br />maintained <br />In N/0 21. Workstation/procedure area decontaminated <br />0 <br />0 <br />In N/0 <br />5. Decontamination/sanitation area separate and <br />0 <br />0 <br />N/A <br />supplied * <br />N/A <br />In N/0 <br />6. Invoices and log kept for disposable, pre- <br />0 <br />0 <br />In N/O <br />22. Chemical disinfectant used <br />0 <br />0 <br />NIA <br />sterilized equipment, backup supplies available * <br />N/A <br />Chemical used: <br />In N/O <br />7. Sharps containers supplied, labeled, used and <br />0 <br />0 <br />In N/O <br />23. Disinfectant used sufficient contact time Wet <br />0 <br />0 <br />NIA <br />disposed of correctly * <br />NIA <br />contact timeprovided: <br />In N/0 <br />8. Jewelry, tattoo and piercing equipment - storage <br />0 <br />0 <br />In N/O <br />24. Barriers available and used as part of <br />0 <br />0 <br />N/A <br />and use <br />N/A <br />I procedure * <br />In N/O <br />25. Products applied tos 1 <br />0 <br />0 <br />N/A <br />useldis ensed aseptically <br />In N/O <br />9. No eating, drinking or smoking - clean clothes <br />0 <br />0 <br />In N/0 <br />26. Storage of inks, pigments, needles, tubes, etc., <br />0 <br />0 <br />N/A <br />N/A <br />In N/0 <br />10. Hands washed effectively and timely <br />0 <br />0 <br />In N/0 <br />27. Jewelry, Inks, Needles etc approved and used <br />0 <br />0 <br />N/A <br />I <br />N/A <br />In N/0 <br />11. Handwashing facilities properly supplied and <br />0 <br />0 <br />In N/O <br />1 28. Cross -contamination avoided during all phases <br />0 <br />0 <br />N/A <br />accessible warm potable water * <br />N/A <br />of procedure <br />In N/O <br />12. Personal protective equipment available and <br />0 <br />0S <br />N/A <br />used a ewash station available * <br />29. Areas separated/no living or sleeping <br />MN i, <br />In N/O <br />O <br />11N/Aquarters/no <br />I <br />animals <br />In N/O <br />30. Floors and walls clean and in good repair, <br />0 <br />0 <br />In N/O <br />- <br />13. Branding is completed with no other customers in 0 <br />0 <br />N/A <br />procedure area <br />N/A <br />adequate light * <br />In N/0 <br />14. Customers eighteen (18) years of age or older <br />0 <br />0 <br />In N10 <br />31. Workstation, surfaces, including chairs, , etc. in <br />0 <br />0 <br />N/A <br />N/A <br />good repair, trash removed frequently <br />In N/0 <br />15. Skin prepared for procedure. <br />0 <br />0 <br />In N/0 <br />32. Permit/registration and required signs posted * <br />0 <br />0 <br />N/A <br />N/A <br />In N/0 16. Client records available -Consent form &0 0 In N/0 33. IPCP and employee training records and 0 0 <br />N/A questionnaire N/A He atitiis B vaccination status present <br />In N/0 17. Aftercare instructions given to client 0 0 In N/0 34 Restrooms available, stocked * 0 0 <br />N/A NIA <br />S"e, Ck 14 <br />Received by (Print): Received by (Signature): 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 />Pagel of 3 <br />