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y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N' 1868 East Hazelton Avenue , Stockton , CA 95202-6232 I M' Telephone : (209 ) 468 - 3420 Fax: (209 ) 464 -0138 Web : www . slqov . org /ehd. 4� 64* HOTEL/ MOTEL OFFICIAL INSPECTION REPORT Name of Facility : Inspection Date : " 'i- �� n Address : I f PE * 0 c1 PR#: 0 Z 6 /� Z Owner/Operator. tA n /� /j h + /i 11J�� Pho :o _ I Annual Inspection ❑ Complaint Inspection ❑ Consultation Inspection ❑ Re- Inspection # Units in Facility : �' # Units Inspected : Reinspection On or About: The items checked below are violations to be corrected . See Reverse Side of this Form for Detailed Summary of violations and Code References. Room (s ) . ❑ Room Cleanliness : Lack of cleanliness & sanitation ; Accumulation of debris , trash , 1 ' garbage , combustible items or similar materials . Room Maintenance : General lack of repair or improper maintenance ; Broken or non. . �e ; tli f 2 functioning sink/toiletlbath ; Lack of hot water . Floors : Not clean , properly covered or in good repair . Walls & Ceilings : Walls/ceilings in need of cleaning or repair: Holes , water Vol �J damage , peeling or deteriorating paint; Dampness or excessive moisture in room . ❑ Heating : Lack of approved heating in each unit; Approved heater not maintained in a safe , 3 . working condition ; Lack of adequate heat (Standard : 70°F at 3 feet from floor) . Drinking Utensils & Ice Buckets : Not protected from contamination ; Lack of or improper ❑ 4 . washing & sanitizing after each use ( multi-use) ; Lack of or improper protective bagging ( multi- use) or individual protective wrapping (single-use) , ❑ 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 . ❑ 6 ' Garbage Receptacles : Inadequate number of garbage receptacles ; Lack of or inadequate close fitting covers ; Garbage receptacles unclean or in disrepair. ❑ Public Areas : Unsafe or unsanitary conditions in kitchen , hallways , stairways , exits , or other 7 ' publicly shared spaces . ❑ 8 . Pest Control : Infestation of insects , vermin or rodents . ❑ 9 . Other Nuisance : Any other condition which is hazardous to health . Other Substandard or Unsafe Conditions : Electrical , structural , or plumbing hazards ; Lack ❑ 1o . of or inadequate smoke detectors or fire extinguishers ; Inadequate lighting ; Inadequate protection fr m weather; Inadequate sewage or water facilities . Pest control Used ? &Yes ❑ No Company Name : VoWn Frequency : A 1� Hotel/Motel Business License? Kyes ❑ No r (� )..IQ 2A Multi-Jurisdictional Violations to be Referred to : ❑ City Building/Code Enforcement/Fire ❑ County Code Enforcement/Fire ❑ Other Rooms inspected : r r 2Z Comments : k e4 le7 61 had ra an All violations in rooms not inspected must also be corrected . fAllArogi4e nons by the Environmental Health Department ill be billed at the current hourly rate . Received By : Title : n a Environment I H c' Phone : Page 1 of V HOTEUMOTEL OR EHD 24-01 4-30- 12