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p4U'" Body Art Inspec& Report • Date: s�a�lIS <br /> N ,Z San Joaquin County Environmental Health Department program n <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: P 1w 511 SIS <br /> (209)468-3420 <br /> OR `P www.siogv.org/ehd Program L�tla0 <br /> Element: <br /> Facility Name Address City Zip Code <br /> Forever Yours Tattoo 606 w. 11ei st. Tracy 95376 <br /> Name of Perm it/Registration Holder Permit Exp. Date Time In Time Out Inspection Type <br /> John Hullar 6/30/15 Routine <br /> The above facility is inspected for compliance with Division 104, Part 15,Chapter 7 of California Health and Safety Code(HSC). <br /> V=Violation C=Corrected On Site <br /> V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION cont. C <br /> ❑ 1 Autoclave:approved and effective-passed integrator Parts replaced between clients-grommets,elastic bands, ❑ <br /> test ❑ ❑ 22. etc. <br /> ❑ 2 Items washed,disinfected,packaged,labeled,and <br /> sterilized ❑ PREVENTING CROSS-CONTAMINATION <br /> ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ <br /> ❑ 4. Integrators used/monthly spore test/log maintained ❑ ❑ 24. Appropriate chemical disinfectant used <br /> ❑ 5 Decontamination/sanitation area separated and supplied F1appropriately. <br /> F1 Chemical used: <br /> Invoices and log kept for disposable,pre-sterilized <br /> ® 6 equipment ❑ El25. Disinfectant used appropriately/sufficient contact time <br /> ❑ 7 Sharps containers labeled, used,and disposed of Elappropriately ❑ Wet contact time provided: <br /> ❑ 8 Jewelry,tattoo and piercing equipment-clean and <br /> ❑ El 26. Barriers used Elsterilized <br /> ❑ 27 Products applied to skin are single use/dispensed ElPRACTITIONER HEALTH AND HYGIENE aseptically <br /> ❑ 9. No eating,drinking or smoking-clean clothes ❑ ❑ 28. Storage of inks,pigments, needles,tubes,etc. ❑ <br /> ❑ 10. Hands washed effectively and timely ❑ ❑ 29. Jewelry, Inks,Needles etc approved and used correctly ❑ <br /> ❑ 11 Handwashing facilities properly supplied and accessible, Cross-contamination avoided during all phases of <br /> warm water El ❑ 30' El <br /> ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES <br /> ❑ 13. Bloodborne Pathogen training ❑ ❑ 31. Areas separated/no living or sleeping quarters ❑ <br /> Source: ❑ 32. Floors and walls clean and in good repair,adequate light ❑ <br /> ❑ 14. Appropriate personal protective equipment available and Workstation,surfaces,including chairs,armrests,etc.in <br /> used ❑ ❑ 33' r_1 good repair <br /> CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ <br /> ❑ 15. Branding is completed with no other customers in <br /> rocedure area ❑ ❑ 35. Operation and employee training records present El <br /> ❑ 16. Customers eighteen(18)years of age or older ❑ COMPLIANCE AND ENFORCEMENT <br /> ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s)submitted for review ❑ <br /> ❑ 18 Client records approved and available-Consent form ❑ <br /> and uestionnaire El El 37. Permits obtained and available <br /> ❑ 19. 1 Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ <br /> MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ <br /> ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ <br /> ❑ 21. Machines cleaned and disinfected between clients ❑ ® 41. Sterile Dressing ❑ <br /> Received b (Print): John Hullar Received by(Signature).— Phone: 209 830-6164 <br /> Specialist(Print): Benjamin Escotto,Sr REHS Special st Si nature: AP 0 Phone: 209 468-3178 <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 1 of 2 <br /> EH-03/2015 <br />