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Body Art Inspection Report Date: September 25,2023 <br /> jl San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: 4120 <br /> (209)468-3420 <br /> •\O•. www.siogv.org/ehd Program <br /> \iFoti� Element: PRO548686 <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PR0548686 Courtney Conely Aril 6,2024 Above Training <br /> Observations and Corrective Actions: <br /> 18. The facilities client consent form and medical questionnaire must include all of the information listed in Form 13, <br /> and are available for inspection. HSC 119303 <br /> OBSERVATION: Medical questionnaire lacks "allergies to latex"question. <br /> CORRECTIVE ACTION: Provide the"allergies to latex"question on the medical questionnaire as listed on Form B. <br /> Notes: <br /> 1. Strech mark and scar camoflauge tattoo procedures performed at this facility. <br /> 2. Sharps Assure Mail Back <br /> 323 A Fairfield Road Unit 6 <br /> Freehold, NJ 07 <br /> 3. 1 observed client records. I observed client identification in computer tablet. <br /> 4. CaviWipes with a 3 minute Kill time is the disinfectant. <br /> 5. 1 observed needles and sterilization certificates for lot#'s Cheyenne 2023-19-022 and Cheyenne 2023-19-022. <br /> 6. 1 observed needles with lot#2022-50-005. Sterilization certificate is lacking. Do not use unless a sterilization certificate is <br /> provided. <br /> Per practitioner these are"practice needles". Needles have been removed from practitioner drawere and placed in a different <br /> location. <br /> 7. Practitioner explained tear down and breakdown of equipment . Hands are washed, gloves are worn and equipment is <br /> sanitized prior to beginning procedure. <br /> CORRECTIONS DUE BY OCTOBER 9, 2023 <br /> Reinspection on/about: A reinspection fee of$162 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />