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COMPLIANCE INFO_2020-2026
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COMPLIANCE INFO_2020-2026
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Entry Properties
Last modified
1/28/2026 12:55:07 PM
Creation date
5/31/2024 2:20:12 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4500 - Medical Waste Program
File Section
COMPLIANCE INFO
FileName_PostFix
2020-2026
RECORD_ID
PR0450009
PE
4522 - ACUTE CARE FACILITY
FACILITY_ID
FA0002562
FACILITY_NAME
Sutter Valley Hospitals dba Sutter Tracy Community Hospital
STREET_NUMBER
1420
Direction
N
STREET_NAME
TRACY
STREET_TYPE
BLVD
City
Tracy
Zip
95376
APN
23308101
CURRENT_STATUS
Active, billable
SITE_LOCATION
1420 N Tracy Blvd
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\cfield
Supplemental fields
Site Address
1420 N Tracy BLVD Tracy 95376
Tags
EHD - Public
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<br /> <br /> <br /> <br />Reinspection on/about:__________________. A reinspection fee of $179 per hour may be charged. Page 2 of 2 <br />EH-7/1/25 <br /> MEDICAL WASTE INSPECTION REPORT <br />San Joaquin County Environmental Health Department <br />1868 E. Hazelton Ave., Stockton, CA 95205 <br />(209) 468-3420 <br />www.sjogv.org/ehd <br /> <br />Date: October 6, 2025 <br />Program <br />Record: PR0450009 <br />Program <br />Element: 4522 – Acute Care Facility <br />_ <br /> <br />Observations and Corrective Actions: <br />24. HSC 118275 (a)(2) – Biohazardous waste, as defined in paragraph (1) of subdivision (b) of section 117690, shall be <br />placed in a biohazard bag and labeled in compliance with section 117630. <br />OBSERVATIONS: <br />1. In the ICU department, in unit G, there was an observed alcohol pad in the pharmaceutical/sharps consolidation <br />container. Operator noted that facility is removing regular trash cans as it is safer to have all waste that isn’t sharps, <br />pharmaceuticals, trace chemotherapy, or pathology waste to be considered biohazardous. Alcohol wrapper, as noted in <br />a phone call to facility educator, should have been placed within the regular biohazardous container. <br />Corrective action: <br />1. Training on the segregation of different types of medical waste for the staff that work with medical waste within the ICU <br />unit. <br /> <br />Corrections due to EHD by October 23, 2025 <br /> <br />A routine medical waste inspection was conducted on October 6, 2025, and the following was noted. <br /> <br />Notes: <br />1. Report is emailed to dawn.kent@sutterhealth.org and garrib1@sutterhealth.org . <br />2. Medical waste hauler is Stericycle. <br />3. Medical waste tracking documents dated 3/28, 4/11, 4/25, 5/2, 5/13, 5/30, 8/1 for 2025 did not include generator <br />signature. Notes were noted on these manifests that stated, “No waste per Dawn Kent” (Dawn noted she did not <br />approve and was unaware medical waste haulers were doing this), “No EVS available”, or “Gate closed”. Dawn noted <br />she had no control over this action as the drivers were doing this on their own accord. Dawn emailed manager of <br />Stericycle to report incidents. Stericycle manager (John Azevedo) has referred this issue to the Transportation Manager <br />for Stockton. <br />4. Biohazardous waste bags meet both ASTM D1709 and ASTM D1922 certifications. <br />5. Autoclave bags contained heat changing strips. <br />6. Biohazardous waste is autoclaved using steam sterilization on-site using a San-i-pak autoclave. <br />7. Reviewed medical waste tracking documents from December 15, 2024 – September 26, 2025 <br />8. Biological indicator logs, San-i-pak cycle logs from December 15, 2024 – October 6, 2025. <br />9. Reviewed San-i-pak calibration logs from 2024 – 2025. San-i-pak training logs for 2024 reviewed. No annual training <br />has been conducted 2025 yet as the autoclave is being upgraded with a new sealing mechanism and training will be <br />conducted after sealing mechanism is installed in the next coming weeks. <br />10. Areas inspected: Wound care, Laboratory, Radiology, Pain Clinic, ICU, OB/GYN, and Autoclave area with designated <br />storage areas. <br />11. No pathology containers were viewed during inspection as they were in rooms that were occupied by patients or staff <br />personnel conducting procedures. <br />12. All soiled utility rooms (interim storage areas) were properly labeled and secure from unauthorized access. <br />13. Medical waste management plan states that the biological indicator test is to be conducted weekly. Ensure weekly <br />testing of the biological indicator testing.
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