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Received by (Print): Received by (Signature): Phone: Specialist (Print) .r Specialist (Signature): Phone: This 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 - of - Reinspection Date (on or about) Body Art Inspection Report Date (AAIWDD/YY) z y County of San Joaquin County, Environmental Health Department 1868 E. Hazelton Ave., Stockton CA 95205 Permit Number 1.� 7 ` (209) 468-3420 www.sigov.org/ehd Permit Type Facility Name Address City Zip Code CT .1 ,✓ U %G 6!26 f _ 1 &4--, C LA q .9 7 b cSGt Nt, &�o 'Vv PermitlRegistration Holder Name Permit Exp. Date Total fime Inspection Type 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 10 •", r, u ... .a.. G".ISTM W I, M,. T D $ E1 COSETi� t+lil�E� In N/O A 1. Autoclave is approved and effective -passed integrator test ❑❑ 0 18. Safe machine design A ® ❑ In 0 f 2. Process of cleaning, labeling, packaging and stedizilng items correctly 13 E13 n N/0 19. Machines cleaned and disinfected between NIA clients ❑ ❑ In IA 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ In NI0 20. Parts replaced between clients - grommets, NIA elastic bands, etc. ❑ I 0 4. Integrators used/monthly spore test/log maintained ❑ ❑ i fA+ir ) _" °tNANW :. ; .�� w, LEI ❑ In I 5.Decontamination/sanitation area separate and supplied * ❑ ❑ in N/0 N/A 21. Workstation/procedure area decontaminated n /0 6. Invoices and log kept for disposable, pre- sterilized equipment, backup supplies available * ® In N/0 NIA 22. Chemical disinfectant used Chemical used: i knoeX 13 13/A In NI0 NIA 7. Sharps containers supplied, labeled, used and disposed of correctly * ❑ In N/0 IA 23, Disinfectant used sufficient contact time Wet contact timeprovided: ❑ ❑ In 0 8. Jewelry, tattoo and piercing equipment -storage and use ❑ ❑ N/O XIA 24. Barriers available and used as part of procedure 13 13A < ._„ A Products applied to skin are single use/dispensed aseptically ❑ In 10 9. No eating, drinking or smoking - clean clothes 11 ❑ 26. N/A Storage of inks, pigments, needles, tubes, etc., ❑ ❑ I N!0 N/A 10. Hands washed effectively and timely ❑ ❑ I N/0 NI 27. Jewelry, Inks, Needles etc approved and used ❑ ❑ I In N/0 11. Handwashing facilities properly supplied and accessible warm potable water * ❑ In28. N Cross -contamination avoided during all phases of procedure E3N/A N/O N/A 12. Personal protective equipment available and used, eyewash station available„ ® ❑ .rig,t5 . �,..,..... 29. Areas separated/no living or sleeping In&/0quarters/no animals © . 13. Dias CiRR., t ENfi t' N/O N/A 30. Floors and walls clean and in good repair, ado uatelight * ❑ ❑ In Iprocedure 13. Branding is completed with no other customers in area ❑ 13 In 10 NIA 14. Customers eighteen (18) years of age or older ❑ In N/0 N/A 31. Workstation, surfaces, including chairs, , etc. in good repair, trash removed frequently * N/O IA 15. Skin prepared for procedure. ❑ ® In N/0 NIA 32. Permit/registration and required signs posted 11 ❑ In N/O NIA 16. Client records available - Consent form & questionnaire ❑ In N/0 NIA 33. IPCP and employee training records and Hepatitis B vaccination status present ❑ In N/O NIA 17. Aftercare instructions given to client 1 ❑ In N/0 NIA 34 Restrooms available, stocked ❑ Received by (Print): Received by (Signature): Phone: Specialist (Print) .r Specialist (Signature): Phone: This 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 - of - Reinspection Date (on or about)