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• 1Yoea• ':�o Body Art Inspection Report _ y County of an Joaquin County, Environmental Health Department ILE 1868 E. Hazelton Ave., Stockton CA 95205 (209) 468-3420 www.sigov.org/ehd Facilitv Name Address City • Date (MM/DD/YY) COPY Permit Number 15i Permit Type --�- Zip Code CT Permit/Registration Holder Name Permit Exp. DatEl Total Time Inspection type kiZ ftp At ae- 6 PSO /3 L rv►n JIA,,A � �- RISK FACTORS AND INTERVENTIONS jr 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 v � t „F� _ 0 r T , U . D�- , �_'(C'OSMEHINE h CLEANIN AND.STERILIZATION _, ; . , :. 'oos {?. s SAFETYANDsSA U, ", ,: our ,:eos. In N/0 1. Autoclave is approved and effective - passed ❑ ❑ In N/O 18. Safe machine design ❑ ❑ N/A inteqrator test. NIA In NIO 2. Process of cleaning, labeling, packaging and . In N/O 19. Machines cleaned and disinfected between ❑ ❑ N/A stedizjing items correctly NIA clients In N/O 3. Autoclave loaded correctly/packages allowed to ❑ ❑ In N/0 20. Parts replaced between clients - grommets,. 0 0 NIA dry NIA I elastic bands; etc. In NIO 4. Integrators used/monthly spore test/log ❑ ❑;� � -' NES IN111URD S --CO T INATION 1 NIA maintained In N10 5. Decontamination/sanitation area separate and ❑ ❑ In N/0 21. Workstation/procedure area decontaminated ❑ 0 N/A supplied * I I NIA In NIO 6. Invoices and log kept for disposable, pre- ❑ El In N/0 22. Chemical disinfectant used ❑ ❑ N/A sterilized equipment, backu supplies available * N/A Chemical used: In N/0 7. Sharps containers supplied, labeled, used and ❑ In NIO 23. Disinfectant used sufficient contact time Wet ❑ ❑ NIA disposed of correctly * N/A contact timeprovided: In NIO 8. Jewelry, tattoo and piercing equipment - storage ❑ In N/0 24. Barriers available and used as part of ❑ ❑ NIA and use N/,4 procedure '� In NIO 25. Products applied to skin are single ❑ ❑ PRACTITIONER HEALTH AND;HYGIENE,,,3r =,_, .W N/A use/dis ensed aseptically In NIO 9. No eating, drinking or smoking - clean clothes ❑ In NIO 26. Storage of inks, pigments, needles, tubes, etc., ❑ ❑ NIA NIA In NIO 10. Hands washed effectively and timely in N/0 27. Jewelry, Inks; Needles etc approved and used ❑ ❑ NIA NIA In N/O 11. Handwashing facilities properly supplied and In N/O 28. Cross -contamination avoided during all phases ❑ ❑ N/A accessible, warm potable water' NIA of procedure In NIO 12. Personal protective equipment available and ❑ BEST`BU$ MESS P CTICES� x� , N/A * used, eyewash station available❑ } CUSOMERSICLIEENTS f " In NIO 29. Areas separated/no living or sleeping ❑ ❑ <'� �= NIA quarters/no animals In NIO 13. Branding is completed with no other customers in ❑ ❑ In N10 30, Floors and walls dean and in good repair, ❑ ❑ N/A procedure area N/A adequate li ht * In N/O 14. Customers eighteen (18) years of age or older In N/0 31. Workstation, surfaces, including chairs, , etc. in ❑ ❑ NIA NIA good repair; trash removed frequently * In N/0 15. Skin prepared for procedure. ❑ ❑ In N10 32, Permit/registration and required signs posted * ❑ ❑ NIA NIA In N/O 16. Client records available- Consent form & ❑ ❑ in N/0 33. IPCP and employee training records and 0 ❑ N/A questionnaire NIA Hepatitiis B vaccination status present In NIO 17. Aftercare instructions given to client in N10 34 Restrooms available, stocked * ❑ ❑ NIA N/A Received by (Print):.Sa(=,e 2e4-+ �Ca ' _ 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. Page -1.0 -f.21 Reinspection Date (on or about)