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Body Art Inspect* Report Date: <br />w. San Joaquin County Environmental Health Department Program <br />1868 E. Hazelton Ave., Stockton, CA 95205 Record: <br />(209) 468-3420 <br />www.sjogv.org/ehd Program F °R Element: <br />Facility Name <br />Forever Yours Tattoo <br />Address <br />606 w eleventh st <br />City <br />Tracy <br />G-2etl { <br />`c oZ0 <br />Zip Code <br />95376 <br />Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type <br />Richard Hullar 6/30/14 Routine <br />The above facility is inspected for compliance with Division <br />V = Violation <br />104, <br />Part 15, <br />C = <br />Chapter 7 of California Health and Safety Code (HSC). <br />Corrected On Site <br />V <br />CLEANING AND STERILIZATION <br />C <br />V <br />MACHINE SAFETY AND SANITATION (cant.) <br />C <br />❑ <br />1 <br />Autoclave: approved and effective - passed integrator <br />test <br />El <br />❑ <br />22. <br />Parts replaced between clients - grommets, elastic bands, <br />E]etc. <br />❑ <br />2 <br />Items washed, disinfected, packaged, labeled, and <br />sterilized <br />❑ <br />PREVENTING CROSS -CONTAMINATION <br />❑ <br />3. <br />Autoclave loaded correctly/packages allowed to dry <br />❑ <br />❑ <br />23. <br />Workstation/procedure area decontaminated <br />❑ <br />❑ <br />4. <br />Integrators used/monthly spore test/log maintained <br />❑ <br />❑ <br />24. <br />Appropriate chemical disinfectant used <br />❑ <br />❑ <br />5' <br />Decontamination/sanitation area separated and supplied <br />appropriately <br />❑ <br />Chemical used: saniwipes <br />® <br />6• <br />Invoices and log kept for disposable, pre -sterilized <br />equipment <br />❑ <br />❑ <br />25. <br />Disinfectant used appropriately/sufficient contact time <br />ElSharps <br />® <br />7' <br />containers labeled, used, and disposed of <br />appropriately <br />ElWet <br />contact time provided: <br />❑ <br />8 <br />Jewelry, tattoo and piercing equipment - clean and <br />sterilized <br />El <br />El26. <br />Barriers used <br />❑ <br />PRACTITIONER HEALTH AND HYGIENE <br />El <br />27' <br />Products applied to skin are single use/dispensed <br />aseptically❑ <br />❑ <br />9. <br />No eating, drinking or smoking - clean clothes <br />❑ <br />❑ <br />28. <br />Storage of inks, pigments, needles, tubes, etc. <br />❑ <br />❑ <br />10. <br />Hands washed effectively and timely <br />[:1 <br />❑ <br />29. <br />Jewelry, Inks, Needles etc approved and used correctly <br />❑ <br />® <br />11. <br />Handwashing facilities properly supplied and accessible, <br />warm water <br />El <br />❑ <br />30' <br />Cross -contamination avoided during all phases of <br />procedure <br />E] <br />❑ <br />12. <br />Hepatitis B vaccination <br />❑ <br />BEST BUSINESS PRACTICES <br />® <br />13. <br />Bloodborne Pathogen training <br />❑ <br />® <br />31. <br />Areas separated/no living or sleeping quarters <br />❑ <br />Source: <br />❑ <br />32. <br />Floors and walls clean and in good repair, adequate light <br />❑ <br />❑ <br />14. <br />Appropriate personal protective equipment available and <br />used <br />❑ <br />❑ <br />33 <br />Workstation, surfaces, including chairs, armrests, etc. in <br />good repair <br />❑ <br />CUSTOMERS/CLIENTS <br />❑ <br />34. <br />Permit/registration posted <br />❑ <br />❑ <br />15. <br />Branding is completed with no other customers in <br />procedure area <br />El <br />El <br />35. <br />Operation and employee training records present <br />❑ <br />❑ <br />16. <br />Customers eighteen (18) years of age or older <br />❑ <br />COMPLIANCE AND ENFORCEMENT <br />❑ <br />17. <br />Skin adequately prepared for procedure <br />❑ <br />❑ <br />36. <br />Plan(s) submitted for review <br />❑ <br />® <br />18 <br />Client records approved and available - Consent form <br />and questionnaire <br />❑ <br />❑ <br />37. <br />Permits obtained and available <br />❑ <br />❑ <br />19. <br />Appropriate aftercare instructions given to client <br />❑ <br />❑ <br />38. <br />Impoundment <br />❑ <br />MACHINE SAFETY AND SANITATION <br />❑ <br />39. <br />Hearing scheduled <br />❑ <br />❑ <br />20. <br />Safe machine design <br />❑ <br />❑ <br />40. <br />Closure <br />❑ <br />❑ <br />21. <br />Machines cleaned and disinfected between clients <br />❑ <br />❑ <br />41. <br />, <br />❑ <br />Received by (Print): John Hullar <br />Received <br />Phone: <br />Reinspecion on/about: A reinspection fee of $125 per hour may <br />EH -04/2014 <br />7 8310 (01(eq <br />468-9673 <br />Page 1 of 2 <br />