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u <br /> ° a� Body Art Inspection Report <br /> Dale: July i6,2024 <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: AP2400709 <br /> (209)468-3420 <br /> w .sioay.ora/ehd Program <br /> �t F qR% Element: 4103 <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> Alekxis Mondra on(BB P Exp. 1/18/25 <br /> Observations and Corrective Actions: <br /> 6. HSC 119315-Invoices and log kept for disposable, pre-sterilized equipment <br /> OBSERVATIONS: <br /> Sterilization certificates were not available for the EX needle cartridges (lot#2022-03-01), Wormhole needle cartridges (lot <br /> #2023/10) or the Big Wasp needle cartridges (lot#03/2024). <br /> CORRECTIVE ACTIONS: <br /> A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and client, <br /> date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone <br /> sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a <br /> minimum of 90 days after use. Provide EHD sterilization certificates for the instruments mentioned above. <br /> 9. HSC 119309-No eating, drinking or smoking -clean clothes—Corrected on site. <br /> OBSERVATIONS: <br /> Food and drinks were observed in the procedure room. <br /> CORRECTIVE ACTIONS: <br /> No food, drink,tobacco product, or personal effects are permitted in the procedure area. <br /> 11. HSC 119314-Handwashing facilities properly supplied and accessible,warm water <br /> OBSERVATIONS: <br /> The paper towel dispenser in the procedure area was not touchless. <br /> CORRECTIVE ACTIONS: <br /> The procedure area shall be equipped with a sink with hot and cold running water, containerized liquid soap, and single use <br /> paper towels dispensed from a wall-mounted, touchless dispenser that is readily accessible to practitioner. Replace the paper <br /> towel dispenser in the procedure area with a dispenser that is wall-mounted and touchless. <br /> 18. HSC 119303-Client records approved and available-Consent form and questionnaire <br /> OBSERVATIONS: <br /> 1. The tattoo (hardcopy) consent form did not include all of the items from Form B. <br /> 2. The tattoo (hardcopy) medical questionnaire did not include all of the items from Form B. <br /> 3. The tattoo (electronic format)consent form did not include all of the items from Form B. <br /> 4. The tattoo(electronic format) medical questionnaire did not include all of the items from Form B. <br /> 5. The permanent cosmetic (electronic format)consent form did not include all of the items from Form B. <br /> 6. The permanent cosmetic(electronic format) medical questionnaire did not include all of the items from Form B. <br /> CORRECTIVE ACTIONS: <br /> 1. The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. Include the following on the tattoo(hardcopy)consent form and provide a copy to the EHD: <br /> -Description of procedure. <br /> -Description of what the client should expect following the procedure. <br /> -Notice that inks are not FDA approved and health consequences are unknown. <br /> Reinspection on/about: A reinspection fee of$172 per hour may be charged. Page 2 of 4 <br /> EH-11/17 <br />