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0.Pq�ly 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.sigov.org/ehd <br /> Fa"`'p HOTEL/MOTEL OFFICIAL INSPECTION REPORT <br /> Name of Facility: Inspectjon ate: <br /> Address: <br /> IAA 100" P <br /> Owner/Operat r: Phone: '(? <br /> Annual Inspection ❑ Complaint Inspection ❑ Consultation Inspection Lt Re-Inspection <br /> #Units in Facility 17-12 #Units Inspected Z y 1 Reinspection On or About: A)IA, <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 /> ❑ 1 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 /> F-1 2 functioning sink/toilet/bath; Lack of hot water. Floors: Not clean,properly covered or in <br /> good repair.Walls&Ceilings:Wallsiceilings in need of cleaning or repair: Holes,water <br /> damage, peeling or deteriorating paint;Dampness or excessive moisture in room. <br /> ❑ 3' 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 /> (mufti-use)or individual protective wrapping(single-use). <br /> ❑ <br /> Bedding: Mattress/linens infested with lice, bedbugs,or other insects; Not free from filth or 5' foul matter: Unsafe;Linens not changed weekly or before new guest. <br /> ❑ 6 Garbage Receptacles: Inadequate number of garbage receptacles;Lack of or inadequate <br /> close fitting covers;Garbage receptacles unclean or in disrepair. <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? Yes ❑ No Company Name: a Frequency: #rdA11XG <br /> Hotel/Motel Business License? [XYes []No <br /> Multi-Jurisdictional Violations to be Referred to:❑City Building/Code Enforcement/Fire❑County Code Enforcement/Fire❑Other <br /> Rooms inspected: (Z 111 Z :I-[I LfvL 22t 72L f-7"( 2 #'ZZ' <br /> Comments: M,Pvor< "+{fi f M,(, Ott 7 r35. 4 rt(- rli3 11 <br /> 'YI'" <br /> All violations in rooms not inspected must also be corrected. <br /> All re-kpdectiAns by the onmenta.l Health Department will be billed at the current hourly rate. <br /> Received By: Title: r, <br /> Environmental Health Specialist: Phone:Z L-01 R) W' _l7ma Page 1 of <br /> EHD 24-01 4-30-12 HOTEUMOTEL OR <br />