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oct!?!fY• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton; CA 95202-6232 <br /> ' Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.si-ov.org/ehd <br /> HOTEL/MOTEL OFFICIAL INSPECTION REPORT <br /> Name of Facility: Inspection Date: <br /> Address: PE: PR#: <br /> N. -W 241-11 W-00 3'r <br /> OwneOperator: P ne: —d 7/ <br /> Annual Inspection El Complaint Inspection [:] Consultation Inspection ❑ Re-Inspection <br /> #Units in Facility: -U #Units Inspected: Reinspection On or About: A/J <br /> The items checked below are violations to be corrected. <br /> See Reverse Side of this Form for Detailed Summary of Violations and Code References. Room(s): <br /> ❑ Room Cleanliness: Lack of cleanliness&sanitation;Accumulation of debris,trash, <br /> garbage,combustible items or similar materials. <br /> Room Maintenance: General lack of repair or improper maintenance; Broken or non- <br /> 2' <br /> ❑ functioning sink/toilet/bath; Lack of hot water. Floors: Not clean,properly covered or in <br /> good repair, Walls&Ceilings:Walls/ceilings in need of cleaning or repair: Holes,water <br /> damage, peeling or deteriorating paint; Dampness or excessive moisture in room. <br /> 3. <br /> Heating: Lack of approved heating in each unit;Approved heater not maintained in a safe, <br /> ❑ working condition;Lack of adequate heat(Standard:70°F at 3 feet from floor). <br /> Drinking Utensils&Ice Buckets: Not protected from contamination; Lack of or improper <br /> ❑ 4. washing&sanitizing after each use(multi-use);Lack of or improper protective bagging <br /> (multi-use)or individual protective wrapping(single-use). <br /> ❑ Bedding: Mattress/linens infested with lice, bedbugs,or other insects; Not free from filth or <br /> 5' foul matter; Unsafe; Linens not changed weekly or before new guest. <br /> ❑ s Garbage Receptacles: Inadequate number of garbage receptacles; Lack of or inadequate <br /> close fitting covers;Garbage receptacles unclean or in disrepair. <br /> ❑ <br /> 7. Public Areas: Unsafe or unsanitary conditions in kitchen, hallways,stairways,exits,or other <br /> publicly shared spaces. <br /> ❑ 8. Pest Control: Infestation of insects,vermin or rodents. <br /> ❑ 9. Other Nuisance:Any other condition which is hazardous to health. <br /> Other Substandard or Unsafe Conditions: Electrical,structural,or plumbing hazards; Lack <br /> ❑ 10. of or inadequate smoke detectors or fire extinguishers; Inadequate lighting; Inadequate <br /> protection from weather: Inadequate sewage or water facilities. <br /> Pest control Used? 5fl Yes ❑ No Company Name: )-),r Frequency: "1vjWj y <br /> Hotel/Motel Business License? (2 Yes ❑ No <br /> Multi-Jurisdictional Violations to be Referred to:❑ City Building/Code Enforcement/Fire❑ County Code Enforcement/Fire❑Other <br /> Rooms inspected: iLl <br /> Comments: <br /> D i r P T r <br /> All violations in rooms not inspected must also be corrected. <br /> All re-inspections by the Environmental Health Department will be billed at the current hourly rate. <br /> Received By: 4 - Title: <br /> Environmental HbaltM Wecialist: Phone: <br /> (Z{pl) ,Ids-f�6r Page 1 of <br /> EHD 24-01 4-30-12 HOTEUMOTEL OR <br />