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Body Art Inspection Report Date(MM/DD/YY) County of San Joaquin County,Environmental Health Department Permit Number -VaQ0AL657-157 1868 E.Hazefton Ave.,Stoddon CA 95205 (209)488-3420 w�.sov.or�/ hd 'W12,"L Permit Type Facility Name Address city Zip Code CT eta [s. iy 1 6nAj:22xA- 6,-if Q:Li�'2f-a Jan-A n6ita-i Permit/Registration Holder Name Permit Exp.Date Total lime Inspection Typeu RISK FACTORS AND INTERVENTIONS Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. In=In Compliance Out=Not in Compliance N/O=Not Observed N/A=Not Applicable COS Corrected On Site -11�1,1 vi .0-11E "a ag gg"ip"m XNE All x. In N/O 1. Autoclave is approved and effective-passed 13 E3 In N10 18. Safe machine design 0 0 N/A int egratortest N/A In N/0 2. Process of cleaning,labeling,packaging and in N/O 19. Machines cleaned and disinfected between 71n N10 N/A! 13 0 In N/O 0 0 N/A stediziing items correctly NIA I clients In N/0 3. Autoclave loaded correctly/packages allowed to1 0 13 In N/0 20. Parts replaced between clients-grommets, 0 [3 NIA dry N/A elastic bands,etc. In N/O 4. Integrators used/monthly spore test/log [3 13 NIA maintained In N/O 5. Decontamination/sanitation area separate and 13 13 In N/O/0 21. Workstation/procedure area decontaminated 0 13 N/A supplied* NIA In N/O 6. Invoices and log kept for disposable,pre- 13 13 In N/0 22. Chemical disinfectant used 0 13 N/A sterilized equipment,backup supplies available N/A Chemical used: In NIO 7. Sharps containers supplied,labeled,used and E3 0 In NIO 23. Disinfectant used sufficlerit contact time Wet U 0 N/A disposed of correctly* N/A contact time provided: In NIO 8. Jewelry,tattoo and piercing equipment-storage 103 0 In N/O 24. Barriers available and used as pad of 0 13 N/A and use N/A procedure In N/0 25. Products applied to skin are single [3 13 N/A useldispe sed aseptically mom in N/O 9. No eating,drinking or smoking-dean clothes 0 0 In N/0 26. Storage of Inks,pigments,needles,tubes,etc., 0 13 N/A NIA I I 1 10 NIA n-WO 27. Jewelry,Inks,Needles etc approved and used In NIO 10. Hands washed effectively and timely 0 0 E3 El N/A NIA In N/O 11, Handwashing facilities properly supplied and 0 0 In N/O 28. Cross-contamination avoided during all phases 13 13 N/A accessible,warm potable water NIA of procedure M WIN In N/O 12. Personal protective equipment available and 0 0 N/A used,eyewash station available In N/0 29. Areas separated/no living or sleeping 0 13 N/A quartersino animals* In N/O 13. Branding is completed with no other customers in 13 0 In NIO 30. Floors and walls dean and in good repair, 0 0 N/A procedure area N/A adequate light* In N/0 14. Customers eighteen(18)years of age or older El 11 In N/0 31. Workstation,surfaces,including chairs,,etc.in 0 0 NIA NIA good repair;trash removed frequently* In NIO 16. Skin prepared for procedure. E3 13 In N/0 32. Permit/registration and required signs posted 0 0 N/A N/A In N/O 16. Client records available-Consent form& I n N/O 33, 1 PCP and employee training records and NIA questionnaire 13 13 NIA Hepafitiis B vaccination status present 0 0 In N10 17, Aftercare instructions given to client [3 0 In N/0 34 Restrooms available,stocked FE17H N/A WA Received by(Print): SLrAC� Received by(Signature): Phone: Specialist_(Print): Specialist(Signature): Phone: F1This report is an Official Notice of Violation.Corrections must be completed in the time specified. A reinspection fee may be charged if Violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page_i of 41