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P°UI/y MEDICAL WASTE INSPECTION REPORT Date: August 28,2024 N, San Joaquin County Environmental Health Department Program ' `. 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: PR0537858 (209)468-3420 Program www.siogv.org/ehd Element: 4522 Observations and Corrective Actions: 12. HSC 117960 -LQG shall file MWMP with the EA OBSERVATIONS: The Medical Waste Management Plan provided by the operator did not include all of the requirements of the Medical Waste Management Act. CORRECTIVE ACTIONS: MWMP shall contain all information listed in HSC 117960. Update the MWMP and provide a copy to the EHD. 13. HSC 117975 -LQG shall maintain treatment and tracking documents for 2 years. OBSERVATIONS: Treatment and tracking records were not available for review. CORRECTIVE ACTIONS: A large medical waste generator required to register with the EHD shall maintain individual treatment operation records, and shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. Provide EHD with treatment and tracking records from August 28, 2022 to August 28, 2024. 19. HSC 118215 -All medical waste shall be treated pursuant to this section. OBSERVATIONS: 1.A positive spore test was observed on March 27, 2024 (see PHOTO 16). A retest was not conducted, per records. 2. Spore tests were provided from November 2023 to February 2024 and from July 2024 to August 2024. Per operator, the facility did not sterilize medical waste from March 2024 to July 2024 due to not having autoclave bags. San-I-Pak sterilization logs indicate the autoclaves ran during that time frame. 3. The annual calibration records for the thermometer was not available for review. CORRECTIVE ACTIONS: 1. The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load processed under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. Ensure positive tests are always retested and documented. 2. The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load processed under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. Operator shall spore test the autoclaves once a month (or according to facility SOP), per each chamber. Operator shall document when the autoclave is not running and keep records for review by the EHD. 3. Thermometers, thermocouples, or other monitoring devices shall be checked for calibration annually. Records of the calibration checks shall be maintained as part of the facility's files and records for 2 years. Provide EHD with the calibration records for the last two years. 24. HSC 118275-Medical, biohazardous,sharps,trace chemo, pathology, or pharmaceutical waste shall be segregated and contained pursuant to this section. The container shall be properly labeled. OBSERVATIONS: 1. Pharmaceutical waste containers located in the Med Rooms of buildings C6-B (see PHOTO 5), C6-A(see PHOTO 6), B1-B (see PHOTO 8)and the designated accumulation area (see PHOTO 18) did not have a closed lid. —Corrected on site 2. The pharmaceutical waste container located in the Med Room of 131-A (see PHOTO 7)was not properly labeled. -Corrected on site 3. Two biohazard containers located in MUT-AB were lined with autoclave bags but not with red biohazard liners. Solid waste was observed in the containers. 4.A chemotherapy waste container located in the designated accumulation area was not properly labeled (see PHOTO 14). — Corrected on site Reinspecion on/about: A reinspection fee of$172 per hour may be charged. Page 2 of 4 EH-2/2023